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DISSERTATION 


ON  THE 


DISEASES  OF  THE 

MAXILLARY  SINUS. 


Read  before  the  American  Society  of  Dental  Surgeons,  at  their  Third  Annual  Meeting, 
held  in  Boston,  July  20,  1842. 


BY  CHAPIN  A.  HARRIS,  M.  D„  D.  D.S. 

PROFESSOR  OF  PRACTICAL  DENTISTRY  IN  THE  BALTIMORE  COLLEGE  OF  DENTAL  SURGERY  J MEM- 
BER OF  THE  MEDICAL  AND  CHIRURGICAL  FACULTY  OF  MARYLAND  ; CORRESPONDING 
MEMBER  OF  THE  WESTERN  ACADEMY  OF  NATURAL  SCIENCES,  ETC.  ETC. 


PHILADELPHIA  : 
LEA  & BLANCHARD. 


1843. 


H 


3 h r i 6 


WOODS  & CRANE,  PRINTERS,  BALTIMORE 


PREFATORY  ADDRESS. 


Mr.  President  and  Gentlemen:— 


At  the  last  meeting  of  this  association,  I had  the 
honour  to  submit  to  your  consideration,  a memoir  on  the 
“Characteristics  of  the  Teeth,  Gums,  &c.  &c.”  and  I 
now  beg  leave  to  submit  another,  on  the  diseases  of  the 
maxillary  sinus  ; and  in  doing  this,  I am  actuated  by  the 
belief,  that  a short,  and  at  the  same  time,  comprehensive 
treatise,  on  the  morbid  affections  of  this  cavity,  would 
not  be  altogether  unacceptable  to  the  members  of  the 
dental  profession. 

Few  works,  devoted  exclusively  to  these  diseases,  and 
none  in  our  own  language,  that  I am  aware  of,  have  ever 
been  published.  Most  that  has  been  written  upon  them 
is  contained  in  works  on  general  surgery ; many  of 
which  are  either  out  of  print,  or  can  be  obtained  only 


26567 


IV 


PREFATORY  ADDRESS. 


with  great  difficulty.  Mr.  Thomas  Bell,  it  is  true,  in  his 
excellent  work,  entitled,  “The  Anatomy,  Physiology,  and 
Diseases  of  the  Teeth,”  treats  upon  them  at  considerable 
length ; but,  it  could  hardly  be  expected  that,  in  a publi- 
cation of  this  kind,  as  much  space  should  be  given  to  the 
diseases  of  this  cavity,  as  their  importance  demands. 
The  description  given  of  them,  however,  by  this  able  and 
accomplished  writer,  discovers  an  accuracy  of  observation 
that  could  only  be  possessed  by  such  as  have  made  them 
a subject  of  close  and  thorough  investigation.  I might 
also  mention  the  names  of  others,  who  have  written  upon 
one  or  more  of  these  affections,  but  it  is  unnecessary  to 
do  so  now  ; I may  hereafter  have  occasion  to  refer  to 
some  of  their  opinions. 

But,  although  the  diseases  of  the  maxillary  sinus,  have 
engaged  the  attention  of  many  able  writers,  little,  com- 
paratively, of  what  has  been  written  upon  them  is 
accessible  to  the  members  generally,  of  the  dental  pro- 
fession ; and  in  view  of  this  fact,  I have  been  induced  to 
attempt  the  preparation  of  a brief  treatise  upon  them. 
That  one  is  needed,  all,  I think,  will  unhesitatingly 
admit ; and  that  it  is  important  that  the  dental  practi- 
tioner should  understand  the  pathology  and  curative  indi- 
cations of  these  affections,  none,  I believe,  will  deny;  for, 
caused  as  they  in  most  instances  are,  by  an  unhealthy 
condition  of  the  teeth,  their  treatment,  as  is  remarked 


PREFATORY  REMARKS. 


V 


by  Mr.  Bell,  “is  so  intimately  connected  with  that  of 
these  organs,  as  to  be  universally  considered  as  forming 
a part  of  the  legitimate  object  of  this  branch  of  practice.” 
With  these  prefatory  remarks,  I shall  proceed,  firstly, 
to  make  a few  general  observations  on  the  morbid  affec- 
tions of  this  cavity,  and  afterwards  to  notice  separately 
each  of  the  diseases  to  which  it  is  liable. 


26567 


CONTENTS 


CHAPTER  I.  page 

Introduction,  ® 

CHAPTER  II. 

Of  Inflammation  of  the  Lining  Membrane, 25 

CHAPTER  III. 

Of  a Purulent  Condition  of  its  Secretions  and  Engorgement,  . . 37 

CHAPTER  IV. 

Of  Abscess, 73 

CHAPTER  V. 

Of  Ulceration  of  the  Lining  Membrane, 89 

CHAPTER  VI. 

Of  Caries,  Necrosis  and  Softening  of  its  Bony  Parietes,  . . 103 

CHAPTER  VII. 

Of  Tumours  of  its  Lining  Membrane  and  Periosteum,  . . . 117 

CHAPTER  VIII. 

Of  Exostoses  of  its  Osseous  Parietes,  . 147 

CHAPTER  IX. 

Of  Wounds  of  its  Parietes  and  Foreign  Bodies  in  it,  . . . 159 


DISEASES  OF  THE  MAXILLARY  SINUS, 


CHAPTER  I. 

INTRODUCTION. 

In  the  remarks  which  I am  about  to  offer  on  the  diseases  of 
the  maxillary  sinus,  it  will  be  unnecessary  to  give  a full  descrip- 
tion of  this  cavity,  inasmuch  as  that  has  been  done,  by  nearly  every 
writer  on  general  anatomy,  since  the  middle  of  the  seventeenth 
century.  It  will  be  sufficient  to  observe,  that  it  is  of  an  irregular 
quadrangular  shape,  and  situated  in  the  middle  of  each  superior 
maxillary  bone,  between  the  orbiter  plate  and  the  palatine  and  al- 
veolar processes,  that  it  is  lined  by  the  pituitary  membrane,  and 
communicates  with  the  nose  by  means  of  an  opening  between  the 
superior  and  inferior  turbinated  bones,  which,  though  large  in  the 
skeleton,  is  not  more  than  one-fourth  or  fifth  the  size  of  a common 
goose-quill  in  the  living  subject,  and  is  always  partially  closed  by 
a duplicature  or  fold  of  the  mucous  membrane.* 

It  was  not  however,  until  the  knowledge  of  anatomy  had 
made  considerable  progress,  that  the  existence  of  this  cavity  was 
known.  Casserius,  an  anatomist  of  Padua,  who  flourished  during 

* Vide  Memoires  de  1’ Academic  de  Chirurgie,  Tom.  12,  edit,  in  12, p.  4. 

2 


10 


INTRODUCTION. 


the  latter  part  of  the  sixteenth  and  early  part  of  the  seventeenth 
centuries,  is  said  to  have  been  the  first  to  discover  it ; but  no  cor- 
rect description  of  it  was  given,  until  about  the  middle  of  the  lat- 
ter, and  to  Nathaniel  Highmore,  author  of  a treatise  on  anatomy,* 
published  in  1651,  the  credit  of  this  belongs.  Hence  the  name  of 
“antrum  highmorianum ,”  by  which  it  is  usually  designated. 

This  cavity  is  subject  to  some  of  the  most  formidable  and 
dangerous  forms  of  disease  that  the  medical  or  surgical  practi- 
tioner is  ever  called  upon  to  treat;  and  yet,  there  are  few  diseases 
incident  to  the  human  body,  that  have  not  received  more  attention 
from  writers  on  pathology  and  therapeutics  than  these.  Diseases 
are  sometimes  here  met  with,  over  which  neither  the  surgeon  nor 
physician  can  exercise  any  control,  and  whose  progress  is  only 
arrested  with  that  of  the  life  of  the  unfortunate  sufferer. 

All  of  the  diseases  to  which  the  antrum  maxillare  is  subject, 
however,  are  not  of  so  dangerous  a character;  some  are  very 
simple  and  easily  cured,  but  even  those  which  are  regarded  as  the 
least  dangerous,  and  that  yield  most  readily  to  treatment,  when 
instituted  during  their  incipient  or  early  stages,  often,  if  neglected 
for  a considerable  length  of  time,  or  if  improperly  treated,  assume 
a new  and  so  aggravated  a form,  as  to  bid  defiance  alike  to  the 
skill  both  of  the  physician  and  surgeon.  But,  while  on  the  one 
hand,  the  most  simple  affections  that  are  here  met  with,  may  by 
neglect  or  improper  treatment,  ultimately  become  incurable;  those 
on  the  other,  which  are  considered  as  the  most  malignant  and 
dangerous  from  their  inception,  might,  I have  no  doubt,  by  a 
timely  and  judicious  employment  of  suitable  remedies,  be  effec- 
tually and  radically  removed. 

* This  work  is  entitled,  “Corporis  Hurnani  Desquisitio  Anitomico.” 


INTRODUCTION. 


11 


The  form  which  the  disease  puts  on,  it  must  be  admitted,  is 
determined  by  the  state  of  the  constitutional  health  or  some  speci- 
fic tendency  of  the  general  system,  and  we  can  therefore  readily 
imagine,  that  a cause  which  in  one  person,  would  give  rise  only 
to  simple  inflammation  of  the  lining  membrane,  or  a mucous 
engorgement  of  the  sinus,  would  in  another,  produce  an  ill  condi- 
tioned ulcer,  fungus  hsematodes  or  asteo-sarcoma.  But  simple 
inflammation  and  mucous  engorgement  of  this  cavity,  not  unfre- 
quently  cause  caries  and  exfoliations  of  its  surrounding  osseous 
tissues,  and  as  a consequence  in  some  instances,  even  the  destruc- 
tion of  the  life  of  the  patient. 

The  importance  then  of  early  attention  to  the  diseases  of 
this  cavity,  is  very  apparent,  and  this  is  the  more  necessary  as  it 
is  often  difficult  and  sometimes  even  impossible  to  determine  the 
character  of  the  malady,  until  it  has  progressed  so  far  as  to  have 
involved,  to  a greater  or  less  extent,  the  neighbouring  parts  ; 
when,  if  it  has  not  become  incurable,  its  removal  is,  at  least,  ren- 
dered more  tedious  and  less  easy  of  accomplishment.  It  may 
therefore,  be  safely  assumed,  that  in  a very  large  majority  of  the 
cases  of  disease  of  the  maxillary  sinus,  the  danger  to  be  appre- 
hended, results  more  from  neglect,  than  any  necessarily  fatal 
character  of  the  malady,  so  that  in  forming  a prognosis,  the  cir- 
cumstances to  be  considered,  should  be,  the  state  of  the  constitu- 
tional health,  the  progress  made  by  the  affection,  and  the  nature 
and  extent  of  the  injury  inflicted  by  it  upon  the  surrounding  tissues. 
If  the  general  health  be  not  so  much  impaired  as  to  prevent  its 
restoration  by  the  employment  of  proper  remedies,  and  the  dis- 
ease has  not  inflicted  extensive  and  irreparable  injury  upon  the 
neighbouring  structures,  the  prognosis  will  be  favourable ; but  if 


12 


INTRODUCTION. 


the  functional  operations  of  the  body  have  become  so  much 
deranged  as  to  prevent  their  restoration,  and  the  bones  of  the  face 
and  nose  have  become  seriously  implicated  with  the  affection  of 
the  sinus,  the  combined  resources  both  of  medicine  and  surgery 
will  prove  unavailing. 

In  young  and  middle  aged  subjects  of  good  constitutions,  a 
morbid  action  may  exist  in  the  antrum  for  years  without  giving 
rise  to  any  very  alarming  symptoms,  while  the  same  species  of 
affection  in  another  less  healthy  constituted,  would  rapidly  extend 
itself  and  degenerate  into  so  malignant  a form  of  disease  as  to 
threaten  the  speedy  destruction  of  the  life  of  the  patient.  Medical 
history  abounds  with  examples  of  this  kind,  and  they  conclusively 
establish,  that  the  state  of  the  general  health  and  habit  of  body, 
whatever  may  have  been  the  primitive  characteristics  of  the 
malady,  ultimately  determine  its  malignancy,  and  that  in  the 
treatment  of  affections  of  this  cavity,  as  well  as  other  local  dis- 
eases of  the  body,  these  should  not  be  overlooked. 

But,  independently  of  the  danger  of  the  affections  which  seat 
themselves  here,  they,  for  the  most  part  are  very  loathsome,  and 
subject  the  patient  to  great  annoyance.  They  change  the  qualities 
of  the  secretions  of  this  cavity  and  cause  them  to  exhale  a very 
nauseating  and'  fetid  odor.  This,  in  many  instances,  is  almost 
insufferable  to  the  patient,  and  when  it  is  considered  that  these 
secretions  must  have  egress  through  some  opening,  and  when  pre- 
vented from  escaping  through  the  natural  one  into  the  nose,  as  is 
often  the  case,  that  they  evacuate  themselves  through  an  artificial 
one  formed  by  art,  or  effected  by  their  own  acrimonious  and  dis- 
organizing qualities,  through  the  cheek,  alveolar  border  or  palatine 
arch,  the  inconvenience,  it  can  readily  be  imagined,  must  be  great. 


INTRODUCTION. 


13 


And,  they  are  not  only  exceedingly  annoying,  but  they  are  also 
sometimes  very  painful ; but  the  degree  and  constancy  of  the  pain 
by  which  they  are  attended,  vary  according  to  their  nature  and 
the  nervous  susceptibility  of  the  individual.  The  pain  is  some- 
times lancinating  and  excruciating  almost  beyond  the  power  of 
endurance,  but  when  it  is  very  severe,  it  is  usually  less  constant ; 
at  other  times  it  is  slight,  but  more  constant. 

The  occurrence  of  disease  in  the  maxillary  sinus,  as  I have 
already  intimated,  is  often  very  insidious.  It  not  unfrequently 
happens  that  it  exists  for  weeks  and  even  months  before  its 
presence  is  suspected — the  slight  uneasiness  occasioned  by  it 
being  attributed  to  some  morbid  condition  of  the  teeth  or  gums, 
and  the  symptoms  attendant  upon  one  description  of  affection  of 
this  cavity,  are  often  so  similar  to  those  that  accompany  another, 
that  it  is  impossible  to  determine  the  character  of  disease  that  is 
developing  itself,  until  it  has  made  considerable  progress. 

But  man  is  not  the  only  animal  that  is  subject  to  morbid  affec- 
tions of  the  antrum  maxillare.  Dr.  Wm.  Cook,*  states  that  while 
residing  in  the  country,  a disease  prevailed  among  cattle  which 
caused  them  to  go  mad,  and  that  it  was  believed  that  they  had 
been  bitten  by  a mad  dog.  Having  a desire  to  ascertain  the  seat 
and  nature  of  the  malady,  which  was  attended  with  such  singular, 
and  in  most  instances,  fatal  effects,  he  examined  the  head  of  one 
that  had  died  of  it.  His  researches  were  first  directed  to  the 
brain,  but  as  no  morbid  appearances  were  there  observable,  he 
next  laid  open  the  superior  maxillary,  and  to  his  great  astonish- 
ment, found  the  antrum  filled  with  fetid  matter.  But  although  he 

* Vide  note  to  Morgagni’s  work  on  the  Seats  and  Causes  of  Diseases,  &c, 
&c.  vol.  i.  page  167. 


14 


INTRODUCTION. 


was  fortunate  enough  to  discover  the  seat  of  the  disease,  he  does 
not  attempt  to  give  any  explanation  of  its  cause,  nor  does  he  even 
state  the  season  of  the  year  at  which  it  prevailed.  The  affection 
however,  evidently  consisted  of  a mucous  engorgement  of  the 
sinus,  accompanied,  most  probably,  by  ulceration  of  its  lining 
membrane  and  caries  of  its  osseous  walls. 

The  morbid  affections  of  the  maxillary  sinus,  are,  for  the  most 
part,  similar  to  those  of  the  nasal  fossae.  There  is,  however,  one 
form  of  disease  which  seems  to  be  peculiar  to  this  cavity,  and 
that  is  mucous  engorgement.  Deschamps  mentions  two,  dropsy 
and  purulent  accumulations,*  but  the  first  of  these,  properly 
speaking,  is  never  met  with  in  this  cavity,  and  authors  who  have 
enumerated  it  among  the  diseases  that  occur  here,  have  evidently 
mistaken  mucous  engorgement  for  it.  The  fluids  that  accumu- 
late here  are  of  a mucous  or  muco-purulent  character,  except 
when  they  are  the  result  of  the  disorganization  of  some  of  the 
surrounding  parts ; then  they  are  sanious. 

Previously  to  the  discovery  of  this  cavity,  the  diseases  of  the 
maxillary  sinus  were  little  understood ; and  though  their  distress- 
ing and  often  fatal  effects  must  have  been  frequently  observed, 
their  real  seat  was  not  known,  and  consequently  the  means  em- 
ployed for  their  cure  could  seldom  have  succeeded  in  accomplish- 
ing it.  They  were  thought  to  have  originated  within  the  substance 
of  the  osseous  tissue,  and  I have  no  doubt,  that  many  of  the  sup- 
posed cases  of  spina  ventosa  and  tumours  of  the  superior  maxillary 
bone,  spoken  of  by  some  of  the  older  writers,  were  morbid  affec- 

*Vide,  Traite  des  Maladies  des  Fosses  Nazales  et  de  leurs  Sinus;  art 
v.  sec.  2,  page  226. 


INTRODUCTION. 


15 


tions  of  this  cavity.  Even  subsequently  to  the  knowledge  of 
the  existence  of  this  antrum,  similar  mistakes  seem  to  have  been 
committed.  Many  cases  of  disease  of  the  superior  maxilla  are 
narrated  by  authors  without  any  mention,  or  even  allusion  to 
this  cavity,  which,  from  the  description  given  of  them,  were 
obviously  seated  in  it.  Several  such  are  recorded  by  Wiseman, 
in  his  treatise  on  surgery,  published  in  1676.*  But  notwith- 
standing his  seeming  ignorance  of  the  seat  of  these  affections,  he 
evidently  had  a pretty  correct  idea  of  their  curative  indications, 
for  the  plan  of  treatment  which  he  adopted  differs  but  little  from 
that  pursued  at  the  present  day. 

The  most  simple  form  of  disease  that  occurs  in  this  cavity,  is 
inflammation  of  its  lining  membrane,  and  this  in  most  instances 
may  be  said  to  precede  all  others.  It  often  subsides  spontaneously, 
but  when  it  continues  for  a long  time,  it  is  apt  to  become  chronic, 
and  then  it  not  unfrequently  gives  rise  to  other  and  more  formi- 
dable kinds  of  disease.  When  unattended  by  any  other  morbid 
affection,  either  local  or  constitutional,  it  is  easily  cured. 

A purulent  condition  of  the  fluids  of  the  antrum  is  a very  com- 
mon affection,  but  it  is  seldom  met  with  in  persons  of  good  con- 
stitutions. It  seems  to  be  dependent  upon  a bad  habit  of  body  and 
inflammation  of  the  pituitary  membrane  of  the  sinus,  which  last 
results  more  frequently  from  dental  irritation  than  any  other  cause. 
This  condition  of  the  secretions  of  the  antrum,  sometimes  gives 
rise  to  caries  and  exfoliation  of  portions  of  the  surrounding  bone, 
and  to  fistulous  ulcers,  but  when  it  is  dependent  upon  no  other 
local  cause  than  simple  inflammation  of  the  mucous  membrane, 

* Vide,  Book  iv.  chap.  iv.  Obs.  12,  13  and  17,  pages  265,  280  and  281. 


16 


INTRODUCTION. 


it  is  seldom  that  such  effects  result  from  it,  but  when  complicated 
with  other  morbid  conditions  of  the  cavity,  they  are  not  unfrequent. 

All  purulent  conditions  of  the  secretions  of  the  pituitary  mem- 
brane of  this  cavity,  are  by  some  denominated  abscess.  The  name 
however,  as  is  justly  remarked  by  Mr.  Thos.  Bell,  is  improper.  Ab- 
scess is  a different  affection,  and  it  is  one,  that  very  seldom  occurs 
here;  yet,  instances  of  it  have  been  met  with,  at  the  extremities 
of  the  roots  of  teeth  that  had  perforated  the  sinus,  and  it  sometimes 
happens  that  when  an  abscess  is  seated  in  the  alveolus  of  a supe- 
rior molaris,  the  matter,  instead  of  making  for  itself  a passage 
through  the  socket  of  the  tooth  on  either  side,  escapes  into  this 
cavity,  and  finally  with  its  secretions,  through  the  nasal  opening. 
Mr.  Bell,  the  gentleman,  whose  opinion  I just  referred  to,  describes 
a case  of  abscess  seated  in  the  upper  part  of  the  antrum,*  but  this 
as  he  himself  states,  is  the  only  one  of  the  kind  on  record. 

Ulceration  of  the  lining  membrane  is  an  affection  less  frequent- 
ly met  with  than  either  of  the  preceding.  It  is  rarely,  if  ever 
idiopathic,  but  seems  rather  to  be  dependent,  both  upon  some  other 
local  malady  and  some  specific  constitutional  vice.  Scorbutic 
and  scrofulous  dispositions  and  those  in  which  there  exists  a vene- 
real taint,  are  by  far  more  liable  to  be  affected  with  ulceration 
of  this  membrane  than  persons  of  sound  constitutions,  and  conse- 
quently local  remedies  alone,  are  seldom  adequate  to  its  cure.  It 
is  almost  always  complicated  with  fungi  of  the  membrane  and 
caries  of  the  walls  of  the  sinus,  and  when  neglected  for  a long 
time,  it  sometimes  takes  on  a cancerous  form  and  becomes  incu- 
rable 

#Anat.  Phys.  and  diseases  of  the  teeth,  page  269. 


INTRODUCTION. 


IT 


Next  in  the  order  of  arrangement,  which  I propose  to  adopt  in 
treating  upon  the  diseases  of  this  cavity,  is  caries  of  its  walls. 
This,  though  always  complicated  with  one  or  more  other  forms 
of  diseased  action,  seems  nevertheless  to  be  worthy  of  separate 
consideration.  Like  ulceration  of  the  lining  membrane,  it  is  an  effect 
of  some  one  or  more  other  affections.  It  may  result  from  accu- 
mulation of  the  secretions  of  the  sinus,  ulceration,  or  from  tumors. 

The  occurrence  of  fungus  and  other  kinds  of  tumors  is  less  fre- 
quent than  any  of  the  preceding  affections,  yet  this  cavity  is  not 
exempt  from  them,  and  they  constitute  the  most  dangerous  de- 
scription of  malady  that  the  superior  maxilla  is  subject  to.  Al- 
though is  it  pi’obable,  that  in  their  incipient  stage,  they  might  in 
nearly  every  instance  be  radically  removed,  it  is  seldom  that  they 
are  cured  after  they  have  attained  a very  large  size,  and  impli- 
cated in  their  morbid  action  to  a considerable  extent  the  circum- 
jacent tissues.  They  have,  however,  been  successfully  extirpated 
even  after  they  had  acquired  so  great  a volume  as  to  have  impli- 
cated to  such  an  extent  the  surrounding  parts,  as  to  have  rendered 
necessary  the  removal  of  the  whole  of  the  superior  maxillary  bone. 
They  usually  grow  with  great  rapidity,  and  when  not  radically 
removed,  are  generally  soon  reproduced. 

Besides  these,  other  varieties  of  disease  are  occasionally  met 
with  here,  and  the  antrum  is  liable  to  injuries,  from  blows  and  other 
kinds  of  mechanical  violence,  and  from  the  introduction  of  insects 
and  other  foreign  bodies ; but  of  these,  it  is  not  now  necessary  to 
to  speak,  as  they  will  hereafter  come  up  for  special  consideration. 

In  regard  to  the  causes  of  the  various  morbid  affections  of  the 

maxillary  sinus,  there  exists  some  diversity  of  opinion.  It  is 

thought  by  some  that  these  diseases  often  result  from  certain 
3 


18 


INTRODUCTION. 


specific  constitutional  vices,  independently  of  any  local  agency 
whatever ; others  attribute  them  to  the  obliteration  of  the  open- 
ing of  this  cavity  into  the  nose;  some  again  suppose  them  to  be 
dependent  upon  the  same  causes  as  are  the  diseases  of  the  nasal 
fossae,  while  others  contend  that  they  are  produced  by  dental  irri- 
tation. Now,  that  all  of  these  may  exert  an  influence  upon  this 
cavity,  is  undeniable;  but  that  some  do  not  do  it  to  the  extent, 
and  in  the  manner  which  many  seem  to  suppose,  is  clear;  and, 
while  I do  not  profess  to  be  at  all  singular  in  the  views  which  I 
entertain  upon  this  part  of  the  subject,  I hope  to  be  able  to  point 
out  some  errors,  into  which,  not  a few  have  evidently  fallen. 
Opinions  are  frequently  formed  or  adopted,  and  conclusions  arrived 
at,  that  are  neither  warranted  by  facts  nor  supported  by  sound 
philosophy,  and  as  it  is  important  to  a correct  knowledge  of  the 
therapeutical  indications  of  at  least,  most  diseases,  that  their 
causes  be  understood,  I shall  endeavpur,  in  the  course  of  the  pre- 
sent treatise,  to  point  out  those  which  are  principally  concerned 
in  the  production  of  the  several  morbid  affections  of  the  maxillary 
sinus,  or  rather  to  explain  the  different  kinds  of  influence,  that 
those  already  mentioned,  are  capable  of  exerting  upon  this  cavity, 
for,  as  I have  before  stated,  I do  not  deny  that  it  is  to  the  presence 
of  some  one  or  more  of  these,  that  the  diseases  to  which  it  is 
liable  are  attributable. 

In  carrying' out  this  design,  it  is  not  my  intention  to  indulge  in 
vague  speculation;  I shall  rely  principally  upon  facts,  to  establish 
the  views  which  I propose  to  advocate,  for  one  fact,  is  worth  a 
dozen  theories  based  upon  no  better  foundation  than  mere  hypo- 
thesis; and  although  the  detail  of  these  be  tedious  and  compara- 
tively uninteresting,  it  is  only  by  their  aid  that  we  can  hope  ic 


INTRODUCTION. 


19 


arrive  at  truth,  and  it  is  this,  that  those,  to  whom  the  treatment  of 
diseases  involving  life,  is  committed,  should  most  desire. 

The  effects  exerted  upon  this  cavity  by  a bad  habit  of  body  or 
constitutional  vice,  are  not  such  as  many  seem  to  suppose.  They 
do  not  amount  to  perceptible  manifestations  of  disease  ; they  only 
consist  in  an  increase  of  the  susceptibility  of  the  tissues  of  which 
it  is  composed,  to  morbid  impressions,  and  when  an  unhealthy 
action  is  lit  up  in  it,  in  a more  aggravated,  and  not  unfrequemly 
different  form  of  disease  than  that  which  would  otherwise  have 
been  produced.  And,  not  only  is  the  susceptibility  of  this  cavity 
to  morbid  impressions  increased  by  an  ill  habit  of  body,  or 
constitutional  vice,  but  that  also,  not  unfrequently,  of  every  part 
of  the  whole  organization;  and  this  increase  of  susceptibility, 
may  exist  for  years,  and  not  result  in  marked  demonstrations  of 
either  general  or  local  disease.  But,  if  the  body,  or  any  part  of 
it,  in  the  meantime,  be  subjected  to  the  action  of  morbid  irritants, 
disease,  either  general  or  local,  according  as  the  whole  or  only  a 
part  of  it  is  acted  upon  by  them,  will  be  the  result.  Again,  the 
same  cause  of  irritation  acting  upon  another,  in  whom  there  exists 
no  constitutional  vice,  and  who,  as  a consequence,  is  not  possessed 
of  so  great  an  aptitude  to  be  morbidly  excited,  might  not  deter- 
mine any  appreciable  unhealthy  action. 

Thus  it  may  be  seen,  that  disease  of  the  maxillary  sinus  is  de- 
pendent upon  some  other  determining  cause  than  a particular  dis- 
position or  vice  of  the  general  system  ; and  yet,  without  this,  no 
morbid  effects  might  be  produced,  or  if  produced,  they  would  be 
of  a different  and  less  aggravated  character.  Any  disposition 
or  vice  of  body,  which  weakens  the  vital  energies  of  the  sys- 
tem, increases  the  susceptibility,  or  what  in  medical  language  it 


20 


INTRODUCTION. 


would  be  more  proper  to  term,  excitability  of  all  its  parts  endow- 
ed with  sensibility,  those  of  this  cavity  equally  with  the  rest. 
There  are  various  kinds  which  have  this  effect : as  for  example, 
the  scorbutic,  scrofulous,  venereal,  mercurial,  &c.  &c.,  each  of 
which,  may  influence  the  character  of  the  morbid  action  excited 
in  it,  in  a manner  peculiar  to  itself,  or  similar  to  that  which  might 
be  exercised  by  another,  and  cause  it  to  assume  a greater  or  less 
degree  of  malignancy,  according  as  the  functional  operations  of 
the  body  generally  are  more  or  less  enervated  by  it. 

This  seems  to  be  the  only  way  in  which  a bad  habit  of  body, 
is  capable  of  affecting  the  maxillary  sinus;  it  is  a predisposing, 
but  not  an  exciting  cause  of  disease,  and  it  is  important  that  this 
distinction  should  be  borne  in  mind, — the  one,  should  never  be  con- 
founded with  the  other,  because  an  error  of  this  sort,  might,  and 
would  in  many  instances,  lead  to  the  adoption  of  incorrect  views 
concerning  the  therapeutical  indications  of  the  disease. 

I might  enlarge  upon  this  part  of  the  subject,  but  it  is  not  ne- 
cessary to  do  so  now,  inasmuch  as  I shall  have  occasion  to  advert 
to  it  hereafter. 

Inflammation  and  even  ulceration  of  the  pituitary  membrane  of 
the  nose,  sometimes  extend  themselves  to  the  maxillary  sinus,  but 
a morbid  action  is  not  so  frequently  excited  in  this  cavity,  by  an 
unhealthy  condition  of  the  nose,  as  the  intimate  relationship  sub- 
sisting between  the  two,  might  lead  some  to  believe.  It  is  seldom 
that  both  are  affected  at  the  same  time,  and  hence  I infer,  that, 
although  lined  by  one  common  membrane,  the  propagation  of  dis- 
ease from  one  to  the  other,  is  an  occurrence,  which  but  rarely 
happens. 

But  although  the  diseases  of  the  nasal  fosste,  may  occasionally 


INTRODUCTION. 


21 


give  rise  to  a morbid  condition  of  the  maxillary  sinus,  it  is  ques- 
tionable whether  the  exciting  causes  of  the  affections  here  met 
with,  ever  act  directly  upon  this  cavity.  Concealed  as  it  is, 
within  the  substance  of  the  superior  maxilla,  and  communicating 
with  the  nose  only  by  means  of  a very  small  opening,  it  would 
seem  to  be  beyond  the  reach,  of  at  least,  most  of  the  causes,  to 
the  action  of  which,  the  diseases  of  the  nasal  fossae  are  attributed. 

The  obliteration  of  the  opening  of  this  cavity,  is  sometimes 
caused  by  disease  in  the  nose,  and  when  this  happens,  it  is  follow- 
ed by  a mucous  engorgement  of  the  sinus,  inflammation  of  its 
lining  membrane,  distention  of  its  osseous  walls,  and  not  unfre- 
quently  by  other  and  more  complicated  forms  of  disease.  But 
the  closing  of  this  opening  is  oftener  an  effect  than  a cause  of 
disease  in  this  cavity,  and  it  generally  re-establishes  itself  without 
any  assistance  of  art,  after  the  cure  of  the  affection  which  caused 
it. 

If  all  the  circumstances  connected  with  the  history  of  the  dis- 
eases under  consideration  could  be  ascertained,  I think  it  would 
be  found  that  these  affections  are  more  frequently  originated  by  a 
morbid  condition  of  the  teeth,  gums  and  alveolar  processes,  than 
any  other  cause.  There  are  no  sources  of  irritation  to  which 
this  cavity  is  so  much  and  so  often  exposed,  as  that  of  the  dental 
organism.  It  is  separated  from  the  apices  of  the  roots  of  the 
superior  molares  and  bicuspides  only  by  a very  thin  plate  of  bone, 
and  it  is  sometimes  even  penetrated  by  them,*  so  that  it  could 

* Some  are  of  the  opinion  that  the  maxillary  sinus  is  never  penetrated  by 
the  roots  of  any  of  the  teeth,  except  in  cases  where  disease  has  destroyed  the 
thin  plate  of  bone  which  usually  covers  the  apices  of  those  immediately  be- 
neath it ; but  that  this  is  incorrect,  is  proven  by  the  fact,  that  both  antra  are 
often  perforated  by  them,  which  would  hardly  be  the  case  were  the  perfora- 


22 


INTRODUCTION. 


scarcely  be  otherwise  than  that  aggravated  and  protracted 
disease  in  the  teeth  and  alveoli  beneath  it,  should  exert  an 
unhealthy  influence  upon  it.  The  pain  occasioned  by  diseased 
teeth,  is  often  very  severe,  sometimes  almost  excruciating,  and 
the  inflammation  excited  by  them  in  the  alveolo-dental  periostea 
and  gums,  frequently  extends  itself  to  the  whole  of  one  side  of 
the  face.  It  could  hardly  be  possible  therefore,  for  this  cavity  to 
escape.  Alveolar  abscess,  and  sometimes  necrosis  and  exfolia- 
tion of  the  socket  of  the  affected  tooth,  result  from  the  inflamma- 
tion thus  lit  up.  It  often  happens  too,  that  the  gums  and  alveolar 
periosteum  are  affected  for  years  with  chronic  inflammation,  and 
other  morbid  affections,  which  it  is  not  now  necessary  to 
enumerate. 

If,  in  addition  to  these  facts,  other  proofs  be  necessary  to  estab- 
lish the  agency  of  dental  and  alveolar  irritation  in  the  production 
of  disease  in  the  maxillary  sinus,  they  may  be  had.  Many  of  the 
affections  that  are  here  met  with,  are  often  cured  by  the  removal 
of  diseased  teeth  after  other  remedies  have  been  employed  in 
vain,  and  that  too,  without  even  perforating  the  antrum.  This 
would  not  be  the  case,  if  the  irritation  arising  from  them  did  not 
extend  to  this  cavity,  and  if  the  disease  in  it  were  not  dependent 
upon  the  irritation  produced  by  them. 

Most  writers  on  these  affections  agree  in  ascribing  them  to  a 
morbid  condition  of  the  teeth  and  alveoli.  There  are  some,  how- 
ever, who  though  they  admit  that  dental  irritation  may  perhaps 

tions  the  result  of  disease,  for  it  rarely  happens  that  both  cavities  are  affected 
at  the  same  time.  Indeed,  I have  never,  except  in  a solitary  instance,  known 
one  antrum  to  be  perforated  by  the  roots  of  the  teeth,  when  the  other  was 
not  similarly  penetrated,  and  it  is  by  no  means  uncommon  for  the  floor  of 
this  cavity  to  be  pierced  by  the  apices  of  the  roots  of  the  first  and  second 
superior  molares. 


INTRODUCTION. 


23 


occasionally  give  rise  to  them,  seem  nevertheless  to  attribute  their 
occurrence  in  the  majority  of  instances  to  other  causes,  such  as 
irregular  exposure  to  cold,  blows  upon  the  face,  and  certain  consti- 
tutional diseases.  Others  again  assert,  that  “if  we  except  caries 
of  the  teeth,  and  the  diseases  of  the  dental  periosteum,  which  can 
be  communicated  to  the  pituitary  membrane,  the  causes  of  these 
diseases  are  unknown.”*  These  are  important  exceptions,  but  that 
they  are  sometimes  traceable  to  other  causes,  there  can  be  no 
question.  It  is  very  certain,  however,  that  these  give  rise  to  them 
more  frequently  than  any  other,  and  in  their  treatment,  the  state 
of  the  health  of  the  teeth  and  alveoli  should  never  be  overlooked. 
. I shall  now  proceed  to  the  consideration  of  the  different  affec- 
tions of  this  cavity,  under  their  respective  and  appropriate  heads. 

* Vide,  Traite  des  Maladies  des  Fosses  Nazales  et  de  leurs  Sinus  3 par  I. 
L.  Deschamps,  fil,  art.  v.  sec.  2,  page  226. 


CHAPTER  II. 


OF  INFLAMMATION  OF  THE  LINING  MEMBRANE. 

As  has  before  been  intimated,  inflammation  when  not  compli- 
cated with  any  other  morbid  affection,  is  the  most  simple  form  of 
disease  to  which  the  pituitary  membrane  of  the  antrum  maxillare 
is  subject.  It  precedes  and  accompanies  all  others  that  are 
here  met  with,  and  it  will  therefore  be  proper  to  offer  a few  re- 
marks upon  it,  before  entering  upon  the  consideration  of  those  of 
a more  aggravated  nature. 

Shielded,  as  the  pituitary  membrane  of  this  cavity  is,  from  most 
of  the  acrid  and  irritating  agents  to  which  it  is  exposed  in  the 
nasal  fossae  and  some  of  the  other  cavities  of  the  body,  it  would 
rarely  here  be  affected  with  inflammation,  were  it  not  that  it  is 
frequently  acted  upon  by  other  morbid  excitants,  whose  immediate 
influence  seldom  extends  beyond  the  alveolar  border  and  face. 
But,  exposed  as  it  is,  to  the  action  of  irritants  of  a very  aggrava- 
ting kind,  inflammation  of  it,  is  of  frequent  occurrence — more  so 
perhaps,  than  many  are  aware  of,  and  it  is  to  this,  that  those  deep 
seated  pains  in  the  superior  maxilla  and  face,  which  are  usually 
denominated  rheumatic,  are,  in  many  instances,  attributable. 

Inflammation  of  the  lining  membrane  of  the  maxillary  sinus, 

when  not  complicated  with  any  general  morbid  tendency,  or  con- 
4 


26 


OF  INFLAMMATION  OF  THE  LINING  MEMBRANE. 


stitutional  predisposition,  seldom  gives  rise  to  any  other  form  of 
diseased  action ; and  it  usually  subsides  spontaneously  on  the  re- 
moval of  the  cause  that  induced  it.  This  membrane  in  good  con- 
stitutions, is  less  subject  to  inflammation,  and  as  a consequence, 
to  any  other  description  of  morbid  action,  than  those  in  whom 
there  exists  some  vice  of  body,  or  unhealthy  predisposition.  Fe- 
brile and  gastric  affections,  eruptive  diseases,  such  as  measles, 
small-pox,  &c.  &c.  syphilis,  an  excessive  and  protracted  use  of 
mercurial  medicines,  a scorbutic  or  scrofulous  diathesis  of  the 
general  system,  and  in  short,  every  thing  that  has  a tendency  to 
enervate  the  vital  powers  of  the  body,  increases  its  irritability. 

When  in  a healthy  condition,  it  secretes  a slightly  glutinous, 
transparent  and  inodorous  fluid,  by  which  it  is  constantly  lubrica- 
ted, but  inflammation,  in  it  changes  its  secretions ; it  causes  them 
to  become  vitiated ; at  first,  to  be  less  abundant,  afterwards  to  be 
secreted  in  larger  quantities  than  usual,  to  be  more  serous,  and  so 
acrid  as  sometimes  to  irritate  the  membrane  of  the  nose  over 
which  they  pass  after  having  escaped  from  the  antrum.  It  also 
causes  them  to  exhale  an  odour  more  or  less  offensive,  according 
as  the  inflammation  is  severe  or  mild.  It  moreover  gives  rise  to 
a thickening  of  the  membrane,  and  sometimes  to  an  obliteration 
of  the  nasal  opening.  This  last,  however,  rarely  occurs,  but 
when  it  does  happen,  an  accumulation  of  the  secretions  and  other 
morbid  phenomena,  of  which  I shall  hereafter  treat,  result  from  it 
as  a necessary  consequence. 

Inflammation  of  the  pituitary  membrane  of  this  cavity,  is  some- 
times followed  by  inflammation  of  that  of  the  nasal  fossae  ; but  I 
am  of  the  opinion,  that  when  this  happens,  it  is  occasioned  by  the 
acrid  qualities  of  the  fluids  that  are  discharged  from  the  sinus  into 
the  nose. 


OP  INFLAMMATION  OP  THE  LINING  MEMBRANE. 


27 


If  at  any  time  during  the  continuance  of  the  inflammation,  the 
patient  is  attacked  with  severe  constitutional  disease,  the  local 
affection  will  be  aggravated  and  sometimes  caused  to  assume  a 
different  character. 

The  inflammation  when  long  continued,  degenerates  into  a 
chronic  form,  and  is  sometimes  kept  up  for  several  years,  without 
giving  rise  to  any  other  unpleasant  effects,  than  occasional  parox- 
ysms of  a dull  and  seemingly  deep-seated  pain  in  the  face,  and  a 
vitiated  condition  of  the  fluids  that  are  secreted  in  this  cavity. 
The  slightly  fetid  odour  which  they  exhale,  ceases  to  be  annoying 
or  even  perceptible  to  the  patient,  as  he  becomes  accustomed  to  it. 

Symptoms. — The  symptoms  by  which  this  affection  is  characte- 
rized, though  not  always  precisely  the  same,  are  nevertheless,  for 
the  most  part,  very  similar.  Boyer  describes  them  to  be  severe, 
fixed,  and  deep-seated  pain  under  the  cheek,  extending  from  the 
alveolar  border  to  the  lower  part  of  the  orbit,  local  heat,  pulsation, 
and  sometimes  fever.*  He  however  tells  us  that  these  symptoms 
are  not  always  present,  and  that  the  disease  sometimes  exists 
when  it  is  not  suspected.  I apprehend  that  this  is  never  the  case. 
Other  affections  of  the  face  and  superior  maxillary,  may  be  mista- 
ken for  this,  and  this  for  others,  but  that  it  should  exist  without 
being  attended  with  pain  or  any  other  signs  indicative  of  its  pre- 
sence, I cannot  believe  to  be  true,  and  I cannot  imagine  how  he 
arrived  at  such  a conclusion. 

Deschamps  distinguishes  the  symptoms  from  those  of  other 
affections  of  this  cavity  by  “a  dull,  heavy  pain  in  the  region  of  it,” 
which  he  says,  “becomes  sharp  and  lancinating,”  and  extends 
from  the  alveolar  arch  to  the  frontal  sinus.  The  disease  goes  on 
* Vide,  Traite  des  Maladies  Chirurgicales,  &c.  &.c.  tom.  vi.  art.  3,  page  138. 


28 


OP  INFLAMMATION  OP  THE  LINING  MEMBRANE. 


i without  interruption,  increasing  until  the  superior  maxilla  of  the 
affected  side  is  more  or  less  involved.  This  malady  he  tells  us  can- 
not be  confounded  with  any  other,  if  there  is  no  external  visible 
cause;  it  differs,  he  says,  from  a retention  of  mucus,  by  being  pain- 
ful at  the  commencement,  and  by  not  being  accompanied  with  swell- 
ing of  the  bones;”  he  distinguishes  it  from  polypus,  as  that  causes 
no  pain,  and  from  cancer,  which  occasions  pain  of  a different  kind. 
“Suppuration  and  ulcers  have  peculiar  signs  which  cannot  be  con- 
founded with  those  of  inflammation.”  Pain  in  the  molar,  and  bicus- 
pid teeth,  accompanied  by  a sense  of  fluctuation  in  the  parts,  he 
seems  to  regard  as  a very  certain  indication  of  inflammation,  and 
especially  when  joined  to  the  other  symptoms.  “If  an  external 
cause,  is  discovered,  it”  he  says,  “will  furnish  a certain  diagno- 
sis,”* he  also  mentions  fever  and  headache  as  almost  invariable 
accompaniments. 

The  inflammation,  if  not  subdued  by  appropriate  remedies,  after 
having  continued  for  a length  of  time,  gradually  assumes  a chro- 
nic form ; the  pain  then  begins  to  diminish,  and  is  less  constant;  it 
becomes  more  dull,  and  is  principally  confined  to  the  region  of  the 
antrum.  The  teeth  of  the  affected  side  cease  to  ache,  or  ache  only 
at  times,  but  still  remain  sensitive  to  the  touch.  The  mucous 
membrane  of  the  nostril  next  the  diseased  sinus,  is  often  tender 
and  slightly  inflamed,  and  if  the  other  one  be  closed  in  the  morn- 
ing, or  after  two  or  three  hours  sleep,  by  pressing  upon  it  with  the 
thumb  or  one  of  the  fingers,  and  a violent  expiration  made 
through  this,  a thin  watery  fluid,  of  a slightly  fetid  odour,  will  be  dis- 
charged, and  pain  will  be  experienced  in  the  region  of  the  antrum. 

*Traite  des  Maladies  des  Fosses  Nazales  et  de  leurs  Sinus;  sec.  2,  art.  ii. 
pages  236-7. 


OF  INFLAMMATION  OF  THE  LINING  MEMBRANE. 


29 


Causes. — The  explanation  of  the  causes  of  inflammation  of  the 
pituitary  membrane  of  the  maxillary  sinus,  as  given  by  Deschamps, 
is  far  from  satisfactory.  After  stating  that  it  is  produced  by  all 
those  general  causes  which  give  rise  to  it  in  other  parts  of  the 
body,”  he  enumerates  among,  what  he  denominates,  “peculiar 
causes,”  a degeneration  of  the  humour  which  it  pours  out,  “blows 
upon  the  cheek,  fractures,  wounds,  and  the  extraction  of  teeth.”* 
What  he  means  by  those  general  causes,  I am  at  a loss  to  under- 
stand, except  it  be  certain  morbid  dispositions  of  body,  irregular 
exposures  to  cold,  &c.  &c.  The  influence  which  these  exert 
upon  the  mucous  membrane  of  this  cavity,  has  been  explained  in 
another  place : it  will  therefore  be  unnecessary  to  repeat  what  has 
already  been  said  concerning  them,  except  it  be  to  state  that  they 
first  exercise  the  same  influence  upon  the  membrane  in  other  parts 
of  the  body,  that  they  do  here,  and  that  this  consists,  not  in  actual 
disease,  but  only  in  an  increase  of  excitability.  The  exciting 
cause  of  inflammation  of  this  cavity,  is  local  irritation,  and,  a dege- 
nerated condition  of  its  secretions,  blows  upon  the  cheek,  wounds 
and  the  extraction  of  teeth,  may  be  enumerated  among  the  agen- 
cies which  are  sometimes  concerned  in  its  production. 

Boyer  says,  “This  inflammation  may  be  produced  by  a blow 
upon  the  cheek,  by  small-pox,  measles,”  &c.  but  the  most  ordinary 
cause  is  caries  and  pain  in  the  teeth.f  The  two  last,  although  not 
mentioned  by  Deschamps,  are  very  frequently  concerned  in  the 
production  of  this  affection.  All  morbid  conditions  of  the  teeth, 
in  fact,  and  of  the  gums,  that  give  rise  to  irritation  in  the  alveolar 

*Traite  des  Maladies  des  Fosses  Nazales  et  de  leurs  Sinus;  Art.  2, 
page  236. 

•fTraite  des  Maladies  Chirurgicales,  &c.  &c.  Art.  iii.  tom.  6,  p.  138. 


V 


30  OP  INFLAMMATION  OP  THE  LINING  MEMBRANE. 

periosteal  tissue,  may  be  regarded  as  among  the  most  frequent  of 
its  exciting  causes.  And,  of  the  affections  of  the  teeth  that  do 
this,  caries,  necrosis  and  exostosis  may  be  mentioned ; also,  loose 
teeth,  and  the  roots  of  teeth  that  have  either  been  fractured  in  an 
attempt  at  extraction,  or  by  a blow  or  fall,  and  left  in  their  sockets, 
or  that  have  remained  after  the  destruction  of  their  crowns  by 
decay.  It  sometimes  happens  too,  that  inflammation  is  excited  in 
this  membrane  by  fractured  alveoli,  but  when  an  accident  of  this 
sort  occurs,  the  detached  portions  of  bone  are  generally  soon 
thrown  off  by  the  operations  of  the  economy,  and  the  cause  being 
removed,  the  inflammation  immediately  subsides.  But  not  so 
with  the  roots  of  teeth.  They  often  remain  concealed  in  their 
sockets  for  years,  except  they  be  removed  by  art.  Nature,  it  is 
true,  makes  an  effort  t.o  expel  them  from  the  jaw,  but  this  is  ac- 
complished only  by  a slow  and  very  tedious  process,  and  not,  in 
* many  instances,  until  they  have  given  rise  to  some  serious  affec- 
tion. But,  of  the  deleterious  effects  that  result  from  roots  of 
teeth  in  the  alveoli,  it  is  not  necessary  n£>w  to  speak ; as  extra- 
neous bodies  they  are  always  productive  of  more  or  less  irritation. 

As  to  the  influence  which  the  diseases  of  the  gums  exert  upon 
.the  alveolar  periosteum,  suffice  it  to  say,  that  it  is  little,  if  any  less 
^hurtful  than  that  resulting  from  the  affections  of  the  teeth.  Dis- 
ease here  is  very  certain  to  communicate  itself  to  that  membrane. 
It  is,  in  fact,  to  the  morbid  affections  of  this  structure,  that  the 
diseases  of  the  alveoli,  are  most  frequently  attributable.  It  is  true, 
the  diseases  of  the  gums,  do  not  often  give  rise  to  acute  alveolar 
periostitis,  but  they  excite  in  the  lining  membrane  of  these  cavities, 
a chronic  inflammation,  which,  if  not  arrested,  sooner  or  later 
eventuates  in  their  destruction,  and  as  a consequence,  to  the  gra- 
dual loosening,  and  ultimately,  loss  of  the  teeth. 


OF  INFLAMMATION  OF  THE  LINING  MEMBRANE. 


31 


Thus  it  may  be  perceived,  how  very  liable  the  periosteal  tissue 
of  the  alveolar  cavities  is  to  become  inflamed;  and,  inflammation 
having  been  lit  up  here,  how  very  easy  it  would  be  for  it  to 
extend  itself  to  the  maxillary  sinus;  and  that  it  often  does  propa- 
gate itself  to  this  cavity,  no  one,  I should  suppose,  could  doubt. 
But,  we  are  not  left  to  mere  conjecture,  or  doubtful  inference,  in 
regard  to  this  matter.  Not  only  is  inflammation,  but  every  other 
form  of  disease  to  which  this  cavity  is  subject,  more  frequently 
traceable  to  alveolo-dental  irritation,  than  to  any  other  cause. 
The  truth  of  this  assertion  is  established  by  the  result  of  the  treat- 
ment of  cases  \vhich  I shall  hereafter  have  occasion  to  notice. 

Having  said  thus  much  concerning  the  causes  of  inflammation 
of  the  lining  membrane  of  the  antrum  maxillare,  I shall  now  pro- 
ceed to  describe  its  remedial  indications. 

Treatment. — The  curative  indications  of  the  affection  under 
consideration  are  simple,  and  for  the  most  part,  similar  to  those 
of  inflammation  in  other  parts  of  the  body.  “Bleeding  from  the 
arm,  feet,  pediluvia,  antiphlogistics,  mild  purgatives,  emollient 
cataplasms,  anodyne  applications  to  the  cheek,  fumigations  to  the 
nose,  by  means  of  an  inverted  funnel,”  says  Deschamps,*  are  the 
means  usually  employed.  Originating,  however,  as  does  most 
frequently  inflammation  of  the  lining  membrane  of  the  maxillary 
sinus,  from  the  irritation  produced  by  decayed,  dead  or  loose 
teeth,  the  removal  of  these,  will,  in  most  cases,  be  all  that  is  re- 
quired to  accomplish  a cure.  This  is  the  practice  which  Boyer 
recommends, f and  Deschamps  says,  “it  is  not  uncommon  for  the 
disease  to  cease  immediately  after  the  extraction  of  an  affected 

* Vide,  Maladies  des  Fosses  Nazales,  sec.  2,  Art.  ii.  p.  238. 
t Vide  Maladies  Chirurgicale,  tom.  vi.  page  139. 


32 


OP  INFLAMMATION  OP  THE  LINING  MEMBRANE. 


tooth.”#  But  when  the  inflammation  is  severe,  its  reduction 
will  be  expedited  by  bleeding  from  the  arm,  saline  purgatives  and 
fomentations  to  the  face.  In  many  cases,  great  benefit  will  be 
derived  from  the  application  of  leeches  to  the  cheek,  as  recom- 
mended by  Mr.  Thos.  Bell.f  I have  known  the  most  decided 
advantage  to  result  from  their  employment;  but,  when  the  dis- 
ease is  dependent,  as  it  in  most  instances  is,  upon  an  unhealthy 
condition  of  the  alveolar  process,  the  first  thing  to  be  done,  is  to 
remove  from  them  all  such  teeth  or  roots  of  teeth,  as  are  produc- 
tive- of  the  least  irritation,  for,  while  any  local  sources  of  irrita- 
tion are  permitted  to  remain,  neither  topical  nor  general  bleeding, 
nor  any  other  treatment  will  be  of  permanent  advantage. 

The  treatment  of  inflammation  of  this  cavity,  however,  may 
be  best  illustrated  by  the  following  cases,  which,  from  very  many 
similar  ones,  that  have  fallen  under  the  author’s  notice,  he  will 
briefly  narrate. 

Case  I. — In  the  spring  of  1840,  W.  H.,  aet.  nineteen,  of  a 
sanguino-scorbutic  temperament,  called  to  consult  me  concern- 
ing a deep-seated  pain,  which  he  had  felt,  for  more  than  two 
months,  in  his  left  cheek.  On  interrogating  him,  I ascertained 
that  he  had  occasionally,  during  this  time,  discharged  a fetid  mat- 
ter from  the  nostril  of  the  affected  side.  For  the  relief  of  the  pain 
in  his  cheek,  leeches  and  anodyne  fomentations  to  the  face,  and 
purgatives  had  been  prescribed,  but  from  these  he  obtained  only 
temporary  relief.  At  length,  his  medical  attendant,  suspecting 
that  the  affection  was  in  some  way  connected  with  his  teeth, 
which  were  in  a very  unhealthy  condition,  advised  him  to  obtain 

* Maladies  des  Fosses  Nazales,  p.  238. 

t Anatomy  Phys.  and  diseases  of  the  Teeth,  p.  251. 


OF  INFLAMMATION  OF  THE  LINING  MEMBRANE.  33 

my  opinion  with  regard  to  the  agency  that  they  might  have  in  its 
production. 

The  first  and  second  molares,  the  third  not  having  yet  ap- 
peared, and  the  two  bicuspides,  on  examination,  I found  so  much 
decayed,  as  to  render  their  restoration  to  health  impossible.  Ab- 
scesses had  formed  in  the  sockets  of  the  first  bicuspis  and  second 
molaris,  and  the  matter  from  which  was  almost  constantly  dis- 
charging itself  from  fistulous  openings  through  the  gum  beneath 
the  upper  lip  and  cheek.  Both  the  bicuspides  and  molares  of  this 
side  were  sensitive  to  the  touch,  and  the  gum  around  them  was  in 
a spongy  and  inflamed  condition. 

Not  being  able  to  institute  any  treatment  that  would  be  of  ser- 
vice to  his- teeth,  and  convinced  that  the  affection  of  his  cheek, 
was  attributable  to  the  irritation  which  they  produced,  I advised 
their  immediate  extraction,  to  which  operation  he  at  once  sub- 
mitted. Four  weeks  afterwards,  he  called  and  informed  me  that 
the  pain  in  his  cheek  subsided  about  ten  days  after  the  removal 
of  his  teeth,  and  that  it  had  not  since  returned. 

Case  II. — Mrs.  L , set.  about  twenty-seven  or  eight,  of  a 

scrofulous  habit,  had  been  at  times  affected,  for  more  than  two 
years,  with  a deep-seated  pain  in  the  right  side  of  her  face,  mid- 
way between  the  orbit  and  alveolar  ridge ; and  on  closing  the  left 
nostril,  and  making  a violent  expiration  through  the  right,  dis- 
charged a slightly,  yet  perceptibly  fetid  mucus  matter,  which 
occasionally  excoriated  the  mucous  membrane  lining  this  cavity 
of  the  nose.  This  pain,  from  the  fact  that  it  was  most  severe  in 
cold  and  damp  weather,  was  thought  to  be  rheumatic.  General 
and  local  bleeding,  fomentations,  mustard  plasters,  purgatives, 
anodynes,  tonics,  and  many  other  remedies  were  in  vain  em- 
ployed. 


5 


34 


OP  INFLAMMATION  OP  THE  LINING  MEMBRANE. 


A severe  paroxysm  of  tooth-ache  about  this  time,  July,  1841, 
more  than  two  years  subsequently  to  the  time  when  she  first  felt  the 
deep-seated  pain  in  her  cheek,  induced  her  to  apply  to  me  for  my 
professional  services.  On  examining  her  mouth,  the  crowns  of 
the  second  molaris,  dens  sapientia,  and  first  bicuspis  of  the  affected 
side  were  destroyed  by  caries;  the  gums  covering  the  sockets  of 
their  roots,  were  inflamed  and  very  sensitive.  It  was  the  roots 
of  the  wisdom  or  third  molar  tooth  that  ached,  and  for  the  allevia- 
tion of  the  pain  of  which,  she  had  called  upon  me.  Extraction 
being  the  only  remedy  that  held  out  the  least  prospect  of  relief,  I 
at  once  proposed  that  operation,  and  at  the  same  time  urged  upon 
her,  the  importance  of  having  the  roots  of  the  second  molaris  and 
first  bicuspis  removed.  A great  deal  of  persuasion  however,  was 
necessary  to  obtain  her  consent,  she  being  of  an  exceedingly  ner- 
vous and  timid  disposition,  but  having  made  up  her  mind  to  sub- 
mit to  the  operation,  she  determined  to  have  it  immediately  per- 
formed. She  had  no  cause  to  regret  their  removal,  for  not  only 
was  she  freed  from  the  annoyance  which  they  occasioned  to  her 
tongue,  gums,  &c.  but  the  operation  was  likewise  followed  by  a 
speedy  subsidence  of  the  pain  in  the  cheek,  and  a cessation  of  the 
fetid  discharge  from  the  nose. 

Case  III. — In  December,  1841, 1 was  consulted,  by  Mr.  S.  M. 

J , twenty-three  years  of  age,  and  of  sanguinous  disposition. 

He  had  been  affected  for  several  months,  with  a dull  heavy  pain, 
which  as  he  said,  seemed  to  be  seated  deep  in  his  right  cheek,  and 
as  in  the  case  last  described,  a fetid  mucus  matter  was  dis- 
charged from  the  nostril  of  the  affected  side,  on  making  a violent 
expiration  through  it,  with  the  other  nasal  cavity  closed.  His 
teeth,  to  all  appearance  were  perfectly  sound,  but  the  gums  around 


OP  INFLAMMATION  OF  THE  LINING  MEMBRANE. 


35 


the  first  and  second  bicuspides  and  first  molaris,  were  inflamed, 
spongy,  and  slightly  ulcerated  between  their  edges  and  the  necks 
of  the  teeth,  from  which,  they  had  separated  up  to  the  edges  of  the 
alveoli.  These  morbid  phenomena,  he  attributed  to  a blow,  which 
he  had  received  from  a fall,  upon  these  teeth  about  two  years 
before.  It  was  immediately  followed  by  pain,  inflammation,  and 
in  about  two  months,  by  the  exfoliation  of  several  small  portions 
of  the  alveolar  processes,  which  came  out  through  the  gum. 
These  were  the  only  unpleasant  effects  which  he  experienced  at 
the  time,  but  there  was  always  afterwards,  a slight  soreness  in 
the  teeth,  that  had  received  the  injury.  This,  as  he  informed 
me,  gradually  extended  itself  higher  and  higher  up  into  the  sub- 
stance of  the  jaw,  until,  about  four  months  previously  to  his  hav- 
ing called  on  me,  when  its  place,  seemed  to  be  taken,  by  the  kind 
of  pain  first  described ; and  soon  after  the  fetid  discharge  from 
the  right  nostril  was  discovered. 

That  the  deep-seated  pain  in  the  right  superior  maxillary,  was 
occasioned  by  inflammation  of  the  mucous  membrane  which  lined 
its  sinus,  I could  not  doubt,  and  that  this  had  resulted  from  the 
alveolar  irritation,  caused  by  the  violence  that  had  been  inflicted 
upon  the  first  and  second  bicuspides  and  first  molares,  to  me,  was 
equally  evident,  and  under  such  circumstances,  the  removal  of  the 
injured  teeth,  seemed  to  constitute  the  proper  curative  indication, 
I therefore,  at  once,  proposed  their  extraction,  which  operation  he 
immediately  submitted  to.  Three  weeks  after,  the  pain  in  his 
jaw  had  entirely  disappeared. 

I could  mention  a number  of  similar  cases,  where  the  pain 
and  other  inflammatory  symptoms,  have  been  relieved  simply 
by  the  removal  of  decayed  and  dead  teeth.  When  the  inflam- 


36 


OP  INFLAMMATION  OF  THE  LINING  MEMBRANE. 


mation  is  dependent  upon  the  presence  of  these,  and  that  it  is 
in  a large  majority  of  cases,  there  can  be  no  question,  their  ex- 
traction will  suffice  in  nearly  every  instance,  to  effect  a cure ; but 
when  it  has  been  produced  by  any  other  cause,  as  for  example,  a 
sudden  exposure  to  cold,  a blow  upon  the  cheek,  fractures  of  the 
alveoli,  &c.  &c.  then  the  application  of  leeches  to  the  gums  and 
cheek,  fomentations,  bleeding  from  the  arm,  purgatives  and  other 
treatment  may  be  called  for. 

This  affection,  as  is  remarked  by  Boyer,*  would  be  of  little  con- 
sequence, were  it  not  that  it  is  liable  to  give  rise  to  other  and  more 
dangerous  forms  of  disease,  such,  for  instance,  as  a purulent  condi- 
tion of  the  secretions  of  this  cavity  or  an  engorgement  of  it.  It 
should  never  therefore,  be  permitted  to  continue,  but  should  be  as 
speedily  arrested  as  possible ; and  for  the  accomplishment  of 
this,  the  means  here  pointed  out,  will,  if  timely  and  properly 
applied,  be  found  fully  adequate. 

Inflammation  of  the  pituitary  membrane  of  the  maxillary  an- 
trum, sometimes  causes  the  opening  into  the  nose  to  become 
closed,  and  when  this  happens,  an  engorgement  of  the  cavity  is 
certain  to  result.  Various  other  morbid  phenomena  also  occasion- 
ally arise  from  it,  but  the  most  common  form  of  disease,  resulting 
from  it,  is  an  altered  or  purulent  condition  of  the  mucous  secre- 
tions of  the  cavity,  and  it  is  this,  which  I propose  next  to  notice. 

* Maladies  Chirurgicale,  tom.  vi.  page  139. 


CHAPTER  III. 


OF  A PURULENT  CONDITION  OF  ITS  SECRETIONS  AND 
ENGORGEMENT. 

A purulent  condition  of  the  secretions  of  the  maxillary  sinus 
and  mucous  engorgement,  are  indiscriminately,  though  very 
improperly,  denominated  by  most  writers  on  the  affections  of 
this  cavity,  abscess.  To  this,  neither  bears  the  slightest  resem- 
blance. Deschamps,  treats  of  the  former  under  the  name  of 
suppuration,  and  the  latter  under  that  of  dropsy.*  In  speaking  of 
the  first  he  ^tufls  us,  “if  after  the  time  of  the  inflammation  has 
passed,  the  surrounding  parts  cease  to  be  painful,  while  the  affec- 
tion still  continues  to  cause  pain  in  the  antrum,  and  the  fever, 
though  diminished,  occurs  at  irregular  intervals,  and  if  the  inflam- 
mation is  followed  by  a pulsating  pain,  we  will  have  reason  to 
suppose  that  an  abscess  has  formed  in  the  sinus ; and,”  he  con- 
tinues, “all  doubts  will  be  removed,  if  on  the  patient’s  inclining  his 
head  to  the  opposite  side,  matter  is  discharged  into  the  nostril,  or 
if  some  tubercles  are  formed  near  the  outer  angle  of  the  eye,  or 
alveolar  border,  which  last  happens  more  frequently ; and  finally  ? 
if  the  purulent  matter  not  finding  any  opening  through  which  to 

* Vide  Maladies  des  Fosses  Nazales,  pages  227  and  239. 


38 


OF  A PURULENT  CONDITION  OF  ITS 


evacuate  itself,  distends  the  sinus  to  such  an  extent  as  to  form  a 
tumour  outwardly  upon  the  cheek.”  In  short,  all  the  symptoms 
which  he  mentions  as  belonging  to  the  disease,  are  those  that 
accompany  the  one  now  under  consideration.  The  matter  he 
says  is  of  a “putrid  serous  consistency.” 

Bordenave  has  fallen  into  a similar  error.  He  too,  terms  an 
altered  state  of  these  secretions,  suppuration  of  the  membrane, 
and  he  tells  us  that  inflammation  is  not  necessary  to  it.  He 
seems  moreover,  to  have  confounded  in  alveolar  abscess  those 
cases  where  the  matter,  instead  of  evacuating  itself  as  it  ordina- 
rily does,  through  an  opening  which  it  makes  for  its  exit  through 
the  alveolus  and  gum  into  the  mouth,  escapes  into  the  antrum, 
with  abscess  of  that  cavity.  Again,  he  asserts  that  the  disease, 
(suppuration  as  he  calls  it)  may  be  independent  of  the  surround- 
ing parts,  and  although  ordinarily  implicated  with  an  altered 
condition  of  them,  he  affirms,  it  is  sometimes  the  effect  of  disease 
primarily  seated  in  this  cavity.* 

There  is  no  doubt  that  a purulent  condition  of  the  fluids  of 
this  cavity  is  often  complicated  with  ulceration  of  the  lining 
membrane,  but  that  the  affection  is  at  all  analagous  to  abscess 
or  suppuration,  its  very  nature  and  situation,  is  sufficient  to  dis- 
prove. “A  reference  to  the  structure  of  the  antrum,”  says  Mr. 
Bell,  “would  appear  to  be  sufficient  to  point  out  the  improba- 
bility, to  say  the  least,  of  the  occurrence  of  abscess  in  such  a 
situation.  That  a mucous  membrane  covering,  in  a thin  layer, 
the  whole  internal  surface  of  such  a cavity,  should  become  the 
seat  of  all  the  consecutive  steps  of  true  abscess,  is  a statement 

* Vide  Memoirs  de  l’Acadcmie  Royale  de  Chirurg.  vol.  12,  p.  8.  12mo. 


SECRETIONS  AND  ENGORGEMENT. 


39 


bearing  on  the  face  of  it  an  obvious  absurdity.”*  But  notwith- 
standing the  seeming  improbability  of  such  an  occurrence,  and  it 
is  certainly  one  that  very  rarely  happens,  abscess  does  neverthe- 
less sometimes  seat  itself  in  this  cavity ; but,  it  is  a different 
affection  altogether  from  that  usually  treated  of  under  that  name. 
I have  already  adverted  to  a case  narrated  by  Mr.  B.,  a de- 
scription of  which,  I intend  hereafter  to  give. 

When  complicated  with  ulceration  of  the  mucous  membrane, 
and  it  is  probable  that  a purulent  condition  of  the  secretions  of 
this  cavity,  in  most  instances  is  thus  complicated,  the  affection  is 
precisely  analagous  to  ozena,  and,  by  many  of  the  older  writers, 
it  is  designated  by  that  name.  Mr.  Bell  describes  it,  and  very 
properly  too,  as  being  similar  to  gonorrhoea — both  diseases  equally 
consisting  of  an  altered  secretion,  in  the  one,  of  the  pituitary 
membrane,  and  in  the  other  of  the  mucous  lining  of  the  urethra, 
which,  in  neither  instance  possesses  any  of  the  characteristics  of 
abscess,  though  the  matter  in  both  is  purulent.f 

It  has  been  before  stated  that  the  obliteration  of  the  nasal  open- 
ing was  more  frequently  an  effect  than  a cause  of  disease  in  the 
maxillary  sinus;  it  does,  however,  sometimes  become  closed, 
from  other  causes  than  an  unhealthy  condition  of  this  cavity,  and 
when  this  happens,  an  engorgement  of  the  sinus  is  the  inevitable 
consequence,  but  the  fluids  thus  accumulated  are  not  always  at 
first  purulent.  They  however  may  become  so,  by  their  reten- 
tion in  the  cavity,  and,  when  the  closing  of  the  opening  is  the 
result  of  previous  disease  in  the  antrum,  the  secretions  are  more 
or  less  altered  from  the  very  first. 

* Anat.  Phys.  and  Diseases  of  the  Teeth,  page  253. 

t do.  do.  page  254. 


40 


OP  A PURULENT  CONDITION  OF  ITS 


The  accumulation  of  the  secretions  of  the  antrum,  whether  in 
a healthy  or  purulent  state,  is  a constant  source  of  irritation  to 
the  lining  membrane,  and  the  pressure  which  they  ultimately 
exert  upon  the  surrounding  walls,  causes  a new  form  of  diseased 
action  to  be  set  up,  that  not  unfrequently  involves  the  whole  of  the 
bones  of  the  face  as  well  as  those  of  the  base  of  the  cranium,  and 
which,  if  not  soon  arrested,  ultimately  destroys  the  life  of  the  pa- 
tient. They,  however,  when  prevented  from  escaping  through 
the  nasal  opening,  eventually  make  one  through  which  to  eva- 
cuate themselves,  and  this  is  sometimes  effected  through  the 
cheek,  at  other  times  beneath  it,  just  above  the  alveolar  ridge,  or 
through  the  palatine  arch  or  alveoli  down  by  the  sides  of  the 
roots  of  one  or  more  of  the  teeth,  and  thus  establish  a fistula, 
from  which  a fetid  matter  will  be  almost  constantly  discharged. 
From  openings  of  this  sort,  the  matter  is  sometimes  evacuated 
for  years,  while  the  disease  in  the  antrum,  in  the  meantime,  very 
frequently,  does  not  seem  to  undergo  any  apparent  change.  At 
other  times  the  membrane  ulcerates  and  the  bony  walls  become 
carious. 

But,  a purulent  condition  of  the  mucous  fluids  of  this  cavity, 
independently  of  caries  of  the  bone,  or  even  of  simple  fistulous 
openings,  is  an  exceedingly  troublesome  and  unpleasant  affection. 
The  odour  from  the  matter  is  of  itself,  often  very  annoying  even 
to  the  patient,  and  when  the  secretions  are  retained  for  some  days 
in  the  sinus  before  they  are  evacuated,  the  fetor  from  them  is 
sometimes  almost  insufferable. 

In  good  constitutions,  the  secretions,  of  the  antrum,  are  not  so 
liable  to  become  purulent,  even  though  they  be  confined  for  a long 
time  in  the  cavity.  It  is  only  in  scrofulous,  scorbutic,  or  debili- 


SECRETIONS  AND  ENGORGEMENT. 


41 


tated  habits  that  they  are  liable  to  become  thus  altered.  Inflam- 
mation of  the  lining  membrane,  the  immediate  or  proximate  cause, 
may  exist  for  years  without  giving  rise  to  it.  The  differences  in 
the  effects  produced  upon  them,  and  the  surrounding  parts,  by  in- 
flammation of  this  membrane  is  owing  to  the  differences  in  the 
state  of  the  constitutional  health  of  those  affected  by  it. 

Where  a puriform  state  of  the  secretions  of  this  cavity  is  com- 
plicated with  ulceration  of  the  membrane,  the  matter  will  have 
mixed  with  it  a greater  or  less  quantity  of  flocculi,  sometimes  of 
so  firm  a consistence,  as  to  block  up  the  nasal  opening,  and  pre- 
vent its  exit.  Mr.  T.  Bell  says,  he  has  seen  more  than  one  case 
in  which  a considerable  accumulation  had  taken  place  in  the  an- 
trum, accompanied  by  the  usual  indications  of  this  affection, 
(muco-purulent  engorgement  of  the  sinus)  when  a sudden  dis- 
charge of  the  contents  into  the  nose,  took  place,  “in  consequence 
of  the  pressure  having  overcome  the  resistance  which  had  ihus 
been  offered  to  its  escape.”*  Cases  of  a very  similar  nature  have 
fallen  under  my  own  observation,  the  history  of  some  of  which 
may  be  given  in  the  course  of  this  essay.  The  formation  of 
these  flocculi  rarely  cease,  except  with  the  cure  of  the  ulcers  of 
the  membrane  ; they  give  rise  to  considerable  irritation,  and  their 
presence  always  constitutes  an  obstacle  to  the  cure.  They  are, 
however,  usually  easily  removed  by  injections. 

The  pituitary  membrane  of  the  antrum  when  in  a healthy  state 
secretes,  as  I have  before  stated,  a transparent,  slightly  glutinous 
and  inodorous  fluid,  which  is  poured  out  only  in  just  sufficient 
quantities  to  lubricate  the  cavity.  But,  no  sooner  is  inflamma- 
tion excited  in  the  membrane,  than  its  secretions  become  more 

* Vide,  Anat.  Phys.  and  Diseases  of  the  Teeth,  p.  258. 


6 


42 


OF  A PURULENT  CONDITION  OF  ITS 


abundant,  and,  at  first  thinner,  but  afterwards  thicker  and  more 
glutinous.*  Their  colour  and  consistence  are  not  always  the 
same.  Instead  of  being  transparent,  they  sometimes  have  a dirty 
opaque  appearance  ; at  other  times  they  assume  a greenish,  whitish 
or  yellowish  colour,  and  in  some  instances  they  bear  a considerable 
resemblance  to  pus,  which,  it  has  been  conjectured,  might  be  ow- 
ing to  a suppuration  of  some  of  the  mucous  follicles  of  the  lining 
membrane  of  the  antrum,  and  a consequent  mixture  of  pus  with 
its  secretions.  Mr.  Bell,  however,  inclines  to  the  opinion  that  it 
is  attributable  to  an  “alteration  simply”  of  the  secretions  of  the 
cavity.f  But  their  colour  and  consistence,  I am  disposed  to  believe, 
are  determined  by  the  degree  of  inflammation,  the  length  of  time 
it  has  existed,  the  state  of  the  health  of  the  lining  membrane,  and 
that  of  the  surrounding  osseous  walls,  the  egress  which  the 
matter  has  from  the  sinus,  and  the  general  habit  of  the  body. 

Mucous  engorgement  of  the  maxillary  sinus  and  purulent  accu- 
mulations, it  has  been  remarked,  are  more  common  to  young  sub- 
jects than  to  middle  aged  ones,  or  persons  in  advanced  life.  An 
eminent  French  writer  says,  that  of  three  individuals  affected  with 
dropsy  (mucous  engorgement)  the  oldest  was  not  twenty  years  of 
age.J  Although  these  affections  are  more  common  to  young  per- 
sons than  individuals  of  advanced  life,  they  are  by  no  means  con- 
fined to  the  former.  Debilitated  habits,  though  not  equally,  of 
every  age,  are  subject  to  them. 

Symptoms. — The  diagnostics  of  the  several  affections  of  the  an- 
trum, as  has  been  intimated  in  a preceding  place,  are  so  much 

* Vide,  Maladies  Chirurgicale,  tom.  vi.  p.  140. 

f Vide,  Anat.  Phys.  and  Diseases  of  the  Teeth,  p.  254. 

J Vide,  Traite  des  Maladies  Chirurgicales  et  des  Operations  qui  leur  con- 
viennent,  tom.  vi.  p.  139. 


SECRETIONS  AND  ENGORGEMENT. 


43 


alike,  that  it  is  often  difficult  to  distinguish  those  that  belong  to 
one  from  those  that  are  attendant  upon  another.  The  symptoms 
of  mucous  engorgement  and  purulent  accumulations,  however, 
are  generally  such,  as  will  enable  the  practitioner  to  distinguish, 
with  considerable  certainty,  these  affections  from  any  others  that 
are  here  met  with.  They  are  always  preceded  by  inflammation  of 
the  lining  membrane;  a description  of  the  signs  of  which,  having  al- 
ready been  given,  I need  not  repeat.  Omitting  these  then,  I will 
at  once  proceed  to  mention  those  by  which  they  are  accompanied. 

Jn  speaking  of  those  which  more  particularly  belong  to  a puru- 
lent condition  of  the  secretions  of  the  antrum,  Deschamps  says, 
the  affection  may  be  distinguished  by  a dull  heavy  pain,  extending 
along  the  alveolar  border ; but,  upon  this  symptom  alone,  little 
reliance  can  be  placed  ; as  it  is  always  present  in  chronic  inflam- 
mation of  the  pituitary  membrane  of  this  cavity.  But  in  addition 
to  this,  he  mentions  the  presence  of  decayed  teeth,  soreness  in 
those  that  are  sound,  and  on  the  patient’s  inclining  his  head  to 
the  side  opposite  the  one  affected,  the  discharge  of  fetid  matter 
from  the  nose.*  These  are  certainly  very  conclusive  indications 
of  purulent  effusion  in  this  cavity.  Bordenave,  after  enumerating 
the  symptoms  indicative  of  inflammation,  mentions  the  following 
as  belonging  to  the  affection  of  which  I am  now  speaking ; viz. 
dull  and  constant  pain  in  the  sinus,  extending  from  the  maxillary 
fossas  to  the  orbit ; a discharge  of  fetid  matter  from  the  nose, 
when  the  patient  inclines  his  head  to  the  opposite  side,  or  when 
the  nose  is  blown  from  the  nostril  of  the  affected  side.f  These 
are  the  symptoms  which  are  mentioned  by  almost  every  writer 

* Vide,  Maladies  des  Fosses  Nazales,  sec.  2,  art.  3,  p.  240. 

t Vide,  Memoirs  de  l’Academie  Royale  de  Chirurgie,  12mo.  tom.  12,  p.  10. 


44 


OP  A PURULENT  CONDITION  OF  ITS 


upon  the  subject,  as  indicative  of  a purulent  condition  of  the  secre- 
tions of  the  maxillary  sinus. 

The  diagnostics  indicative  of  engorgement,  differ  materially 
from  those  which  denote  simply  a purulent  condition  of  the 
mucous  secretions  of  this  cavity.  The  pain  instead  of  being  dull 
and  heavy,  as  just  described,  becomes  acute,  and  a distressing 
sense  of  fullness  and  weight  is  felt  in  the  cheek,  accompanied  by 
redness  and  tumefaction  of  the  integuments  covering  the  antrum.J 
The  nasal  opening  having  become  closed,  the  fluids  of  the  cavity 
gradually  accumulate  until  they  fill  it,  when,  finding  no  egress, 
they  press  upon  and  distend  the  surrounding  osseous  walls,  caus- 
ing those  parts  which  are  the  thinnest  ultimately  to  give  way. 
The  effects  are  generally  first  observable  anteriorly  beneath  the 
malar  eminence,  where  a smooth  hard  tumour  presents  itself, 
covered  by  the  mucous  membrane  of  the  mouth.  But  this  is  not 
always  the  point  which  first  gives  way,  the  sinus  sometimes 
bursts  into  the  orbit,  at  other  times  outwardly  through  the 
cheek,  or  through  the  palatine  arch.  The  long  continued  pres- 
sure that  is  thus  exerted  upon  the  bony  walls  of  this  cavity, 
often  cause  them  to  become  softened,  by  the  destruction  of  their 
calcareous  molecules. 

The  tumour  which  is  at  first  hard,  in  a short  time  becomes  so 
soft  as  readily  to  yield  to  pressure.  A distention  of  the  maxillary 

sinus,  Deschamps  says,  may  be  distinguished  from  other  diseases 

« 

that  affect  the  skin  or  intermediate  structure  between  it  and  the 
bone,  by  the  uniformity  or  regularity  of  the  tumour,  its  firmness 
at  the  commencement,  the  slowness  with  which  it  progresses,  and 

f Vide  Bell  on  the  Teeth,  p.  256,  see  also  Maladies  des  Fosses  Nazales, 
page  228. 


SECRETIONS  AND  ENGORGEMENT. 


45 


above  all,  by  the  natural  appearance  of  the  skin,  and  the  absence 
of  pain  when  pressure  is  made  upon  the  tumour.  An  obliteration 
of  the  nasal  opening  he  says,  may  be  suspected  by  the  dryness  of 
the  nostril  of  the  affected  side,*  the  mucous  membrane  of  which 
becomes  thickened,  and  the  cavity  contracted;  inflammation  and 
sponginess  of  the  gums,  loosening,  and  sometimes,  (in  consequence 
of  the  destruction  of  their  sockets,)  displacement  of  the  teeth,  may 
also  be  mentioned  as  occasional  accompaniments  of  engorge- 
ment of  this  cavity  .f 

Causes. — On  the  causes  of  these,  in  common  with  the  other  ' 
affections  of  the  maxillary  sinus,  I have  before  spoken ; it  will  not 
therefore,  be  necessary  to  say  much  in  this  place  concerning  them. 

It  may  be  well,  however,  to  repeat,  that  the  secretions  of  this 
cavity  rarely  become  purulent  in  individuals  possessed  of  good 
constitutional  health,  so  that  it  would  seem,  that  although  local 
irritation  be  necessary  to  it,  this  is  capable  of  producing  it  only 
in  those  labouring  under  a bad  habit  of  body,  or  in  whom  their 
exists  a tendency  to  such  alteration.  Inflammation  of  the  lining 
membrane,  no  matter  how  produced,  is  the  immediate  cause, 
and  this,  as  has  been  before  shown,  results  more  frequently 
from  alveolo-dental  irritation,  than  from  any  other  cause ; and  I 
am  not  the  only  one  that  is  of  this  opinion; — it  is  maintained  by 
almost  every  writer  upon  the  morbid  affections  of  this  cavity. 
The  teeth  that  are  most  frequently  concerned  in  the  production  of 
irritation  in  the  lining  membrane  of  the  antrum,  are  the  first,  and 
second  molares,  but  the  bicuspides  and  dens  sapientiee,  do  some- 
times cause  it.  But,  it  being  conceded  by  nearly  every  one  that 

* Vide  Maladies  des  Fosses  Nazales,  pages  228-9. 

t Vide,  Anat.  Phys.  and  Diseases  of  the  Teeth,  p.  2 57. 


46 


OP  A PURULENT  CONDITION  OP  ITS 


the  exciting  cause,  of  not  only  this,  but  also  all  the  diseases  of  this 
cavity,  is  dental  irritation,  I need  not  spend  time  in  recapitulating 
what  has  before  been  said  upon  the  subject,  or  in  controverting 
absurd  and  erroneous  opinions. 

Engorgement  of  the  sinus  is  attributed  to  several  causes, 
among  which,  are  blows  upon  the  cheek,  caries  of  the  teeth,  &c. 
&c.  But,  whatever  may  be  the  exciting  or  primary  causes  of 
this  affection,  it  is  certain  that  the  proximate  or  immediate  cause, 
is  the  closing  or  obliteration  of  the  nasal  opening.  This,  like 
purulent  secretion,  may  be  produced  by  inflammation  and  thicken- 
ing of  the  lining  membrane  of  the  sinus,  which  is  perhaps  the 
most  frequent  cause.* 

Treatment. — The  curative  indications  of  muco-purulent  secre- 
tion and  engorgement  of  the  maxillary  sinus  are,  1st,  If  the  nasal 
opening  be  closed,  the  evacuation  of  the  retained  matter;  2dly, 
The  removal  of  all  local  and  exciting  causes  of  irritation ; 3dly, 
and  lastly,  the  restoration  of  the  lining  membrane  .f 

For  the  fulfillment  of  the  first,  an  opening  must  be  made  into 
the  antrum,  and  this  should  be  effected  in  that  part  which  will 
afford  the  most  easy  exit  to  the  retained  matter;  but  as  it  regards 
the  several  methods  that  have  been  proposed  for  the  accomplish- 
ment of  this  object,  practitioners  differ;  and,  before  I proceed 

# Fauchard  says,  in  the  Anatomical  Mus.  of  the  University  of  Copenha- 
gen, he  saw  caries  of  the  bones  of  the  face  produced  by  a molar  tooth,  the 
crown  of  which  having  turned  outwards,  had  penetrated  the  maxillary  sinus. 
Mem.  de  l’ Academic  de  Chirurg.  vol.  v.  mem.  25 7.  Also  the  fangs  of  the 
bicuspides  and  front  molaris  sometimes  penetrate  the  sinus.  Benin  Osteo- 
logie,  vol.  xi.  p.  309 — Portal  Camp.  d’Anatomie  Medicale,  vol.  i.  p.  210. 
Note  2. — My  Uerzichniss,  No.  3278  ; there  are  in  the  Bresl.  Mus.  No.  8128, 
two  teeth,  as  it  were  absorbed,  which  had  been  drawn  out  of  the  maxillary 
sinus. — Otto’s  Compend.  of  Comp.  Anal. 

| Vide  Anat.  Phys.  and  Diseases  of  the  Teeth,  p.  259. 


SECRETIONS  AND  ENGORGEMENT. 


47 


further,  it  may  not  be  amiss  to  notice  some  of  the  various  methods 
that  have  been  adopted. 

Dr.  Drake,  an  English  anatomist,  and  author  of  a work  enti- 
tled “Anthropologia  Nova,”  has  the  credit  of  being  the  first  to 
propose  a plan  for  the  evacuation  of  accumulated  fluids  from  this 
cavity,  and  the  method  adopted  by  him  for  effecting  this  object, 
consists  in  the  extraction  of  a molar  tooth  and  the  perforation  of 
the  sinus  through  the  alveolus  of  one  of  its  roots.  This  method  of 
treatment  however,  is  said  by  some  to  have  been  inserted  into 
Drake’s  anatomy  by  Dr.  Cowper,  an  eminent  anatomist  and  sur- 
geon,* but  having  never  seen  any  evidence  touching  the  correctness 
of  this  conjecture,  I suppose,  its  truth  is  probably  somewhat  ques- 
tionable. M.  Gunz  says  the  credit  belongs  to  John  Henry  Meibo- 
mius,  who  a long  time  before  proposed  a very  similar  method  of 
treating  these  affections. f Henry  Meibomius,  many  years  after 
the  death  of  his  father  John  Henry,  proposed  for  the  evacuation  of 

accumulated  fluids  in  the  antrum,  the  extraction  of  one  or  several 

t 

teeth.J  But,  the  perforation  of  the  maxillary  sinus  through  the 
alveolus  of  a molar  tooth,  is  said  not  to  be  the  most  ancient  method. 
Molinetti,  as  early  as  the  year  1675,  describes  an  opening  made 
through  the  cheek  into  the  antrum,  the  wall  of  which,  after  hav- 
ing been  exposed  by  a crucial  incision  through  the  integuments 
covering  it,  was  penetrated  with  a trephine.  And,  the  perforation 
of  this  cavity  through  the  alveolus  of  a superior  molaris,  is  an 
operation  which,  according  to  Velpeau,  was  performed  by  Zwin- 
ger  a long  time  before  it  was  performed  by  Meibomius ; and 

* Heister’s  Surgery,  note  to  chapter  72,  p.  445. 
fVide,  Mem.  de  l’Acad.  Royale  de  Chirurg.  12mo.  vol.  xii.  p.  12. 
f Vide,  Discurs.  de  Abscessibus  internis,  Dresd.  1718,  p.  114,  and  la  Dis- 
sertation d’Gunz. 


48 


OF  A PURULENT  CONDITION  OF  ITS 


Vanuessen,  says,  Ruysch,  extracted  several  molares  and  caute- 
rized their  sockets,  for  the  destruction  of  a polypus,  until  an  open- 
ing was  made  into  the  antrum  large  enough  to  admit  the  finger.* 
But  Drake,  according  to  Bordenave,  seems,  nevertheless,  to  be 
entitled  to  the  credit  of  having  been  the  first  to  perforate  the 
maxillary  sinus  through  the  alveolus  of  a molar  tooth,  by  means 
of  a punch,  for  the  evacuation  of  accumulated  fluids,  and  the  in- 
jection of  the  cavity.  We  are  also  informed  by  the  same  author, 
that  Cowper  treated  a case  of  maxillary  ozena,  which  had  caused 
a large  quantity  of  ichorous  and  fetid  matter  to  be  discharged 
through  the  nose,  by  extracting  the  first  molaris  and  perforating 
the  antrum  through  the  alveolus  with  an  instrument  suited  to  the 
purpose.f 

It  is  not  at  all  probable  that  Meibomius  was  the  first  to  propose 
the  perforation  of  the  antrum  through  the  alveolus  of  a molar 
tooth,  for  his  researches  were  not  published  until  1718,  twenty- 
one  years  after  the  publication  of  Drake’s  system  of  Anatomy, 
and  besides,  he  regarded  the  perforation  of  this  cavity  as  a dan- 
gerous operation,  and  on  that  account,  confined  himself  simply 
to  the  extraction  of  a tooth.  Saint  Yves,  says  Velpeau,  treated 
with  success,  a person  affected  with  fistula,  the  floor  of  whose 
orbit  had  been  destroyed,  by  the  removal  of  a tooth.J 

With  regard  to  the  tooth  most  proper  to  be  extracted,  authors 
differ.  Cheseldon  preferred  the  first  or  second  molaris,  Junker 
recommends  the  extraction  of  the  first  or  second  bicuspides,  and 
if  a fistula  had  formed,  to  enlarge  it  instead  of  perforating  the 

* New  Elements  of  Operative  Surgery,  p.  446. 
t Mem.  de  l’Acad.  Royale  de  Chirurg.  vol.  12,  12mo.  p.  13. 
t New  Elements  of  Operative  Surgery,  p.  446. 


SECRETIONS  AND  ENGORGEMENT. 


49 


floor  of  the  antrum.  It  is  at  present  pretty  generally  conceded 
that  the  second  molaris,  it  being  directly  beneath  the  most  de- 
pendent part  of  the  cavity,  is  the  most  suitable  tooth  to  be  removed  ; 
but,  if  this  be  sound,  the  first  molaris,  dens  sapientise,  or  either  of 
the  bicuspides,  if  carious,  should  be  extracted  in  its  stead,  and  in 
fact,  none  of  the  teeth  that  are  in  an  unhealthy  condition  should 
be  permitted  to  remain. 

An  opening  having  been  effected  through  the  alveolus  of  a 
tooth  into  the  antrum,  it  should  be  kept  open  until  the  health  of 
the  cavity  be  restored.  For  this  purpose,  sounds  and  bougies 
adapted  to  the  purpose  have  been  introduced.  Heuerman,  recom- 
mends the  employment  of  a small  canula,  which  is  also  preferred 
by  Bordenave  and  Richter,  the  latter  of  whom  says,  it  should  be 
kept  closed  to  prevent  particles  of  food  from  getting  into  the 
sinus.  But,  whether  a canula  or  bougie  be  introduced  into  the 
opening,  it  should  be  so  secured  as  to  prevent  it  from  coming  out 
or  getting  up  into  the  antrum.  Deschamps  recommends  that  it  be 
fastened  to  one  of  the  adjoining  teeth  by  means  of  a silk  or  metallic 
ligature.* 

Lamorier,  an  eminent  surgeon  of  Montpellier,  recommended 
perforating  the  antrum  immediately  above  the  first  molaris,  or 
rather  between  it  and  the  malar  bone.  In  this,  he  seems  to  have 
been  influenced  by  the  consideration  that  the  wall  of  the  cavity 
here,  present  the  least  thickness,  and  that  this  is  the  most  de- 
pendent part  of  the  sinus.  But,  if  a fistulous  opening  had  pre- 
viously formed  in  some  other  place  in  the  mouth,  he  did  not 
always  deem  it  necessary  to  make  another.  His  method  of  ope- 
rating is  as  follows.  The  jaws  being  closed,  the  commissure  of  the 
* Vide,  Maladies  des  Fosses  Nazales,  sec,  2,  Art.  1,  p.  234. 


7 


50 


OF  A PURULENT  CONDITION  OF  ITS 


lips  are  drawn  outwards  and  slightly  upwards  with  a curved 
instrument,  called  a speculum ; this  done,  the  gum  is  incised 
across  the  malar  apophasis,*  or  maxillo-labial  sulcus, f and  the 
bone  made  bare,  which  is  next  pierced  with  a spear-pointed 
punch.  The  opening  is  afterwards  enlarged  if  found  necessary. 

Desault  is  of  the  opinion  that  the  opening  should  be  made 
through  the  canine  fossa,  beneath  the  upper  lip,  and  for  that 
purpose,  after  having  laid  bare  the  bone,  he  employed  a sharp 
triangular  and  a blunt-pointed  perforator,  which  he  invented  for 
the  operation.  Runge  says,  Velpeau  used  nothing  but  a scalpel. 
Charles  Bell  invented  a trephine  for  the  purpose,  but  this,  it  is  thought 
does  not  possess  any  advantage  over  the  instruments  employed  by 
Desault  and  Runge.  In  cases  of  fistula  in  the  cheek  from  the 
antrum,  Ruffel  advises  the  insertion  of  a trocar,  to.be  carried 
through  the  gum,  so  as  to  form  a counter  opening.  Through 
this,  in  a case  which  he  treated,  he  passed  a seaton,  and  it  re- 
mained six  weeks  ; at  the  expiration  of  this  time,  a cure  was  ac- 
complished. This  practice  has  been  followed  by  Callisen,  Zang, 
Busch,  Henkle,  Bertrandi,  Faubert  and  others  J Callisen  is  of  the 
opinion  that  when  the  tumour  points  in  the  palatine  arch  and  a 
fluctuation  is  felt,  the  artificial  opening  should  be  formed  there. 
Gooch,  says  Velpeau,  in  a case  which  he  treated,  advised  the  per- 
foration of  the  antrum  through  the  nasal  surface,  and  fixing  in  the 
opening  a canula  of  lead.  We  are  also  informed  by  the  same 
author,  that,  Acrel,  after  having  operated  in  the  manner  proposed 
by  Cowper,  inserted  a second  canula  into  the  sinus  through  a 

* Vide,  Mem.  de  l’Acad.  Royale  de  Chirurg.  12mo.  vol.  12,  p.  37. 

t Vide,  Velpeau’s  Surgery,  p.  447. 

f Vide,  Mem.  de  l’Acad.  Royale  de  Chirurg.  12mo.  vol.  12,  Obs.  IS  and 
21 ; also  New  Elements  of  Operative  Surgery,  p.  447. 


SECRETIONS  AND  ENGORGEMENT. 


51 


fistulous  opening  that  had  formed  in  the  nose.  The  method 
attributed  to  Wienhold,  consists  in  penetrating  the  sinus  from  the 
upper  and  external  part  of  the  canine  fossa,  with  the  instrument 
directed  obliquely  downwards  and  outwards,  so  as  to  avoid  the 
branches  of  the  infra-orbital  nerve ; and  then  placing  in  the  open- 
ing thus  made  a little  lint.  Weinhold,  directs,  that  when  the 
antrum  has  no  other  opening,  the  instrument  to  be  carried  entirely 
through  the  palatine  arch,  and  then  by  means  of  a curved  needle 
and  thread,  he  introduces  a roll  of  lint,  saturated  or  covered  with 
some  appropriate  medicine,  and  this  he  designs  to  act  as  a seton.* 
Velpeau  says,  the  perforation  is  effected  “in  the  point  of  election 
or  of  necessity.  The  first  varies  according  to  the  ideas  of  the 
operator.  The  circumstances,  on  the  contrary,  determine  the 
second.  In  cases  of  abscess,  dropsy,  fistulse,  and  ulceration,  the 
operation  is  almost  always  performed  in  the  place  of  election. 
Then,  provided  one  of  the  molar  teeth  be  unsound,  it  must  be 
extracted,  together  with  the  adjoining  tooth ; the  gum  is  then  to 
be  cut  down  to  the  bone,  externally  ; internally,  behind  and  before, 
forming  a kind  of  a square  flap,  and  to  be  completely  detached 
from  the  surrounding  tissues ; after  this  the  alveoli  are  to  be  perfo- 
rated with  the  instruments  of  Desault,  and  an  opening  made  large 
enough  to  admit  the  finger  into  the  sinus.”*  For  the  evacuation 
simply  of  purulent  mucus,  or  accumulated  fluids,  I believe  with 
Boyer, f that  the  opening  should  always  be  made  from  beneath  ; 
and,  I am  the  more  convinced  of  the  importance  of  giving  the 
alveolus  of  an  extracted  tooth  the  preference,  from  the  considera- 
tion that  it  is  to  the  irritation  produced  by  some  one  or  more  of 

# New  Elements  of  Operative  Surgery,  p.  448. 

t Vide,  Maladies  Chirurgicale,  tom.  vi.  p.  149. 


52 


OF  A PURULENT  CONDITION  OF  ITS 


these  organs,  that  these  affections  are  attributable.  Even  though 
a fistula  may  have  been  formed  above  the  alveolar  ridge,  beneath 
the  cheek,  or  in  the  palatine  arch,  we  should  not  neglect  to 
extract  such  teeth,  whether  carious  or  sound,  as  may  be  produc- 
tive of  irritation.  It  may  not  always  in  such  cases  be  necessary 
to  perforate  the  sinus  from  the  socket  of  a tooth,  though  the  cure 
in  most  instances  would  be  expedited  by  it. 

Jourdain,  an  eminent  French  dentist,  and  graduate  in  surgery, 
instead  of  seeking  egress  for  matter  accumulated  in  the  maxillary 
sinus,  by  any  of  these  methods,  proposed,  in  a memoir  which  he 
presented  to  the  academy,  in  1765,  to  probe  the  cavity  by  its 
natural  opening  and  then  by  suitable  injections  to  restore  it  to 
health.  The  academy  gave  this  proposition  its  attention  ; it  was 
carefully  and  minutely  discussed.  The  practicability  of  obtaining 
entrance  into  the  sinus  in  this  way  was  called  in  question ; it  was 
contended  that  the  difficulties  presented  by  the  peculiar  structure 
of  the  parts  were  such  that  they  could  seldom  be  overcome ; but 
to  remove  all  doubt  upon  the  subject,  a trial  was  determined  on. 

While  this  subject  was  before  the  academy,  M.  Allouel,  jr, 
claimed  the  credit  of  the  discovery  for  his  father,  who,  he  said 
made  it  in  1737,  and  treated  with  success  in  1739,  a case  of 
disease  in  the  antrum  by  injecting  it  through  the  natural  opening. 
But,  the  academy  determined  that  inasmuch  as  M.  Allouel  had 
never  published  it,  Jourdain  could  not  have  borrowed  it  from 
him,  and  was  therefore  entitled  to  the  credit  of  being  the  dis- 
coverer. It  is  certain  that  he  was  the  first  to  announce  it  to  the 
world. 

The  instruments  employed  for  probing  and  injecting  the  sinus 


SECRETIONS  AND  ENGORGEMENT. 


53 


are,  says  Bordenave,*  1st,  a small  silver  sound  with  a button  on 
one  end,  and  a plate  in  the  form  of  a heart  at  the  other,  to  be  held 
between  the  fore-finger  and  thumb  of  the  operator : 2d,  a hollow 
sound  without  either  button  or  plate,  containing  a stilet  of  whale- 
bone, with  its  extremity  extending  beyond  the  sound  between  the 
fingers : 3d,  a small  syringe,  with  a pipe  adapted  to  the  hollow 
sound.  The  two  first  instruments  should  be  curved  something 
like  the  letter  S,  and  vary  a little  in  size. 

The  treatment  of  affections  of  the  maxillary  sinus  by  injections 
through  the  nasal  opening,  having  been  almost  entirely  abandon- 
ed, a more  minute  description  of  the  instruments  employed  for 
the  purpose  is  not  deemed  necessary.  But  it  may  be  well,  be- 
fore dismissing  this  part  of  the  subject,  to  state  that  the  acade- 
my, when  this  method  of  treatment  was  proposed  by  Jourdain,  at 
once  appointed  commissioners  to  investigate  its  merits,  who, 
after  having  made  a number  of  trials,  came  to  the  conclusion 
that  the  introduction  of  a sound  by  the  nasal  opening,  although 
perhaps  possible,  was  so  exceedingly  difficult,  that  it  could  seldom 
be  effected.  They  attempted  it  upon  each  antrum  of  five  sub- 
jects, and  the  result  proved  that  the  sound  pierced  the  membranes 
between  the  turbinated  bones  more  frequently  than  it  entered  the 
sinus  by  the  natural  opening.  Their  report  was  therefore  unfa- 
vourable, and  Bordenave  in  remarking  upon  this  method  of  gain- 
ing access  to  the  cavity,  states  that  while  the  membranes  between 
the  ethmoidal  and  inferior  turbinated  bones  may  be  pierced  with- 
out causing  serious  injury,  it  induces  us  when  it  happens,  to  sup- 
pose that  we  have  entered  the  sinus  by  the  natural  opening, 
which  “goes  to  prove  that  the  operation  is  as  difficult  as  it  is  un- 

* Vide  Mem.  de  l’Acad.  de  Chirurg.  12mo.  vol.  12,  p.  47. 


54 


OF  A PURULENT  CONDITION  OF  ITS 


certain.”  He  adds,  however,  that  while  there  are  cases  in  which 
the  use  of  injections  through  the  natural  opening  will  suffice  to 
effect  a cure,  these  would  succeed  in  only  a very  small  number  of 
the  cases,  inasmuch  as  these  diseases  result  more  frequently  from 
morbid  conditions  of  the  teeth  than  from  any  other  causes.* 

The  only  advantage  then,  as  is  justly  remarked  by  the  last 
named  author,  that  is  derived  from  injections,  is  the  cleansing  of 
the  membrane  of  the  antrum,  or  the  disgorgement  of  the  cavity, 
and  this,  while  the  cause  remains,  will  not  suffice  to  effect  a cure, 
while  the  removal  of  that,  and  the  giving  of  vent  to  purulent  or 
accumulated  fluids  will  of  themselves,  in  most  instances,  be  all  that 
is  required  to  bring  about  a healthy  action.  The  cure,  no  doubt, 
will  many  times  be  greatly  facilitated  by  the  employment  of  suit- 
able injections,  but  that  these  exercise  as  great  a curative  influence 
as  many  imagine,  I have  yet  to  be  convinced.  They  may  in 
those  cases  where  a morbid  action  has  been  kept  up  so  long  in 
the  mucous  membrane  of  this  cavity,  as  to  have  nearly  destroyed 
its  power  to  re-act,  be  highly  serviceable,  but  the  difficulty  of 
doing  this  through  the  natural  opening,  as  is  shown  by  the  result 
of  the  experiments  of  the  commissioners  appointed  by  the  French 
Academy,  and  those  of  others,  who  have  attempted  it,  is  such 
as  must  forever  preclude  their  introduction  in  that  way. 

Moreover,  M.  Allouel  and  Jourdain,  who  have  attempted  to 
establish  the  efficacy  of  injections,  by  the  citation  of  cases,  seem 
to  have  overlooked  the  agency  which  the  removal  of  the  causes, 
during  the  employment  of  the  injections,  had  in  bringing  about 
the  cure  ; so  that  arguments  advanced  by  them  in  favour  of  their 
method  of  treatment  do  not  prove  any  thing  in  its  favour.  “They 

# Vide,  Mem.  de  l’Acad.  Royale  de  Chirurg.  vol.  xii.  12mo.  p.  51 


SECRETIONS  AND  ENGORGEMENT. 


55 


might,”  as  Bordenave  justly  observes,  “just  as  well  have  been 
cured  without  as  with  them.”*  Boyer,  in  alluding  to  the  method 
proposed  by  Allouel  and  Jourdain,  asserts  that  it  is  opposed  both 
to  reason  and  experience. f It  is  also  condemned  by  almost  every 
writer  upon  the  diseases  of  this  cavity. 

When  the  natural  opening  is  closed,  the  first  indication,  as  has 
been  stated,  is  the  evacuation  of  the  matter  and  for  this  purpose, 
a perforation  should  be  made  into  the  sinus,  and  the  most  proper 
place  for  effecting  this,  it  has  been  shown,  is  through  the  alveolar 
cavity  of  the  second  molaris.J  It  may  however  be  penetrated 
from  that  of  either  of  the  other  molares  or  bicuspides.  The  perfo- 
ration, after  the  extraction  of  the  tooth,  is  made  with  a strait  tro- 
car, which  will  be  found  much  more  convenient  than  those  usually 
employed  for  the  purpose.  The  point  of  the  instrument  after 
having  been  introduced  into  the  alveolus,  through  which  it  is  in- 
tended to  make  the  opening,  should  be  pressed  against  its  bottom 
in  the  direction  towards  the  centre  of  the  antrum.  With  the 
handle  of  the  instrument  in  the  hand  of  the  operator,  a few  rotary 
motions  will  suffice  to  pierce  the  intervening  plate  of  bone.  If 
the  first  opening  be  not  sufficiently  large,  its  dimensions  may  be 
increased  to  the  necessary  size,  by  means  of  a spear-pointed  instru- 
ment. In  introducing  the  trocar,  care  should  be  taken  to  pre- 
vent a too  sudden  entrance  of  the  instrument  into  the  cavity. 
Without  this  precaution,  it  might  be  suddenly  forced  into  it  and 
against  its  opposite  wall.  The  entrance  of  it  is  usually  attended 
with  a momentary  severe  pain,  and  its  withdrawal  followed  by 
ed  by  a sudden  gush  of  fetid  mucus. 

*Mem.  de  l’Acad.  de  Chirurg.  vol.  xii.  p.  52. 

t Maladies  Chirurgicale,  vol.  vi.  p.  149. 

f Vide,  Anat.  Pliys.  and  Diseases  of  the  Teeth,  p.  261 . 


56 


OF  A PURULENT  CONDITION  OF  ITS 


It  is  not  always  necessary  to  perforate  the  floor  of  the  antrum 
after  the  extraction  of  a tooth ; it  occasionally  happens,  as  has 
already  been  remarked,  that  some  of  the  alveolar  cavities  com- 
municate with  it. 

An  opening  having  thus  been  effected,  it  should  be  prevented 
from  closing,  until  a healthy  action  shall  have  been  established  in 
the  lining  membrane,  and  for  this  purpose  a bougie  or  leaden  or 
silver  canula  may  be  inserted  into  the  opening  and  secured  in  the 
manner  as  previously  noticed,  to  one  of  the  teeth.  It  should, 
however,  be  removed  for  the  evacuation  of  the  secretions  of  the 
antrum  at  least  twice  a day.  The  establishing  of  an  opening  at 
the  base  or  most  dependent  part  of  the  sinus,  will,  in  those  cases 
where  a fistula  has  been  previously  formed,  in  most  instances,  be 
followed  by  its  speedy  restoration.  Having  proceeded  thus  far, 
the  cure  will  be  aided  by  the  employment  of  such  general 
remedies  as  may  be  indicated  by  the  state  of  the  constitutional 
health,  and  for  the  reduction  of  the  local  inflammation,  leeches  to 
the  gums  and  cheek  will  be  found  very  serviceable.  The  an- 
trum should,  in  the  meantime,  be  injected  with,  at  first,  some 
mild  or  bland  fluid,  and  afterwards  with  gently  stimulating  liquids.* 
Diluted  port  wine,  a weak  solution  of  the  sulphate  zinc,  and  rose 
water  and  also  that  of  copper  and  rose  water, f have  been  recom- 
mended. Diluted  tinct.  of  myrrh  may  sometimes  be  advanta- 
geously employed,  and  when  the  membrane  is  ulcerated,  a weak 

* Anat.  Phys.  and  Diseases  of  the  Teeth,  p.  262. 

f The  following  are  the  formula  of  Mr.  Thomas  Bell. 

R.  Zinci  Sulphat,  grs.  vi.  R.  Cupri  Sulphat,  gr.  iv. 

Aqua  Rosse,  f.  § vi.  M.  Aqua  Roste,  f.  § vi.  M. 

In  addition  to  the  above  he  recommends  the  subjoined. 

R.  Tinct.  Myrrh,  3 i. 

Decoct.  Hordei,  f.  § vi.  M. 


SECRETIONS  AND  ENGORGEMENT. 


57 


solution  of  the  nitras  argentum*  will  be  highly  serviceable.  For 
correcting  the  fetor  of  the  secretions  of  this  cavity,  a weak  solu- 
tion of  the  chloride  of  soda  or  lime,  may  be  injected  into  the 
antrum. 

Dr.  Isaac  I.  Greenwood,  an  eminent  dentist  of  New  York, 
employed  with  success  in  a case  of  muco-purulent  secretion  of 
the  antrum,  caused  by  an  alveolar  abscess,  “suds  made  from 
tepid  soft  water  and  old  Castile  soap,”  and  he  mentions  another, 
treated  in  the  same  way  by  his  father,  the  late  Mr.  John  Green- 
wood.f 

In  cases  of  muco-purulent  secretion  simply,  a weak  decoction 
of  galls, J may  be  injected  into  the  sinus  with  very  considerable 
advantage. 

Injections  of  a too  stimulating  nature  are  sometimes  employed. 
This  should  be  carefully  guarded  against,  by  making  them  at 
first  very  weak,  and  afterwards  increasing  their  strength  as  occa- 
sion may  require ; but  when  symptoms  of  a violent  character  are 
in  this  way  produced,  they  should  be  combatted  by  leeches  to 
the  gums  and  fomentations  to  the  cheek. 

But,  dependent  as  these  affections  in  most  instances  are,  upon 
local  irritants,  greater  reliance  is  to  be  placed  on  their  removal, 
and  the  giving  vent  to  the  acrid  puriform  fluids  in  the  sinus,  than 
to  any  therapeutical  effects  exerted  upon  the  cavity  by  injections. 
As  adjuvants,  they  are  serviceable,  but  a cure  cannot  be  accom- 
plished by  them,  while  the  exciting  cause  remains  unremoved. 

* This  should  at  first  be  used  very  weak,  say  in  the  proportion  of  one 
grain  of  Nit.  Arg.  to  two  ounces  of  soft  water.  Its  strength,  however,  may, 
if  necessary,  be  gradually  increased. 

t Vide  American  Journal  of  Dental  Science,  vol.  2,  p.  179. 

{R.  Gallae  Pulv.  5 ii. 

Aqua  Font,  f.  § vi.  M. 


8 


58 


OP  A PURULENT  CONDITION  OF  ITS 


This  opinion  is  sustained  by  the  result  of  the  treatment  in  the  two 
following  cases. 

Case  IV. — Mr.  W.  S , get.  twenty-four  years,  of  a full 

habit,  and  slightly  disposed  to  scorbutus,  applied  to  me  in  the 
spring  of  1839,  to  obtain  my  opinion  with  regard  to  an  affection 
of  his  left  antrum.  It  had  existed  for  nearly  a year,  and  the  floor 
of  the  sinus  had  been  perforated  through  the  alveolus  of  the  second 
molaris,  which  had  been  previously  extracted.  Injections,  first 
of  diluted  tinct.  of  myrrh,  and  afterwards  of  a solution  of  the  sul- 
phate of  zinc,  diluted  port  wine,  &c.  &c.  had  been  used  regularly 
once  or  twice  a day  for  eight  months  ; but  still,  the  matter  that 
was  discharged  whenever  the  opening  was  unclosed,  was  exceed- 
ingly fetid.  It  had  a thick  muddy  appearance,  and  turned  silver 
black  almost  immediately  on  being  brought  in  contact  with  it. 

Before  the  antrum  was  perforated  from  beneath,  this  fetid  matter 
was  discharged  from  the  nose,  which  at  first,  had  induced  the 
belief,  that  the  affection  was  ozena.  The  heavy  pain  daily  felt 
in  the  cheek,  and  the  occasional  sudden  discharges  of  puru- 
lent matter  from  the  left  nostril,  when  laying  upon  his  right  side, 
led  the  medical  attendant  to  suspect  that  the  disease  was  seated 
in  the  maxillary  sinus,  and  for  the  purpose  of  introducing  what 
he  conceived  to  be  the  proper  remedies,  perforated  its  floor 
through  the  alveolus  of  the  second  molaris,  as  just  stated.  The 
operation  was  immediately  followed  by  a discharge  of  purulent 
and  very  fetid  matter. 

The  use  of  injections,  although  persisted  in  for  so  long  a time, 
were  not  productive  of  any  permanent  benefit,  and  the  patient  had 
almost  begun  to  despair  of  a cure.  His  teeth  had  been  examined, 
but  as  none  in  the  left  side  of  the  upper  jaw  appeared  to  be 


SECRETIONS  AND  ENGORGEMENT. 


59 


affected  with  caries,  they  were  not  suspected  as  having  any 
agency  in  the  production  of  the  disease.  On  examining  his  mouth, 
however,  I at  once  perceived  that  although  the  teeth  were  free 
from  decay,  they  were  nevertheless  coated  with  tartar.  His  gums 
were  inflamed  and  tumefied  ; their  edges  around  the  bicuspides, 
the  first  molaris  and  dens  sapientias,  were  ulcerated,  and  the  alveoli 
so  much  wasted  that  the  teeth  were  considerably  loosened,  and  sen- 
sitive to  the  touch. 

Such  being  the  condition  of  his  teeth,  gums,  and  alveoli,  the 
cause  of  the  affection  in  the  antrum,  was  to  my  mind  apparent. 
That  it  was  attributable  to  the  irritation  in  the  two  last,  I felt 
fully  convinced,  and  therefore  advised  the  immediate  extraction 
of  the  above-mentioned  teeth,  and  to  this  operation,  as  a dernier 
resort,  he  reluctantly  submitted.  Four  weeks  after  their  removal 
the  secretions  of  the  antrum  ceased  to  be  offensive,  and  the  open- 
ing through  the  alveolus  of  the  second  molaris  was  permitted  to 
close.  The  injections  it  is  true,  that  had  been  previously  employ- 
ed, were  continued,  but  as  they  had  not,  previously  to  the  removal 
of  the  teeth,  exerted  any  curative  effect  upon  the  affection  of  the 
maxillary  sinus,  it  is  not  fair  to  presume  that  they  had  subse- 
quently. It  was  therefore  evidently  to  the  extraction  of  these  that 
the  restoration  of  the  cavity  was  attributable. 

Case  V. — In  the  summer  of  1840,  Mr.  B.  of  a strumous  habit, 
aet.  nineteen,  applied  to  me  for  advice,  concerning  an  affection  of 
the  right  maxillary  sinus,  that  had  troubled  him  for  several  months. 
He  informed  me  that  nearly  a year  before,  he  had  broken  the  crown  * 
of  one  of  his  teeth;  (the  second  bicuspis  of  the  affected  side,) 
and  that  a few  weeks  after  he  was  seized  with  a severe  throb- 
bing pain  in  its  alveolus;  this  gradually  extended  to  his  cheek,  but 


60 


OP  A PURULENT  CONDITION  OF  ITS 


in  the  course  of  a few  days,  it  abated  in  intensity,  though  the  pain 
had  never  entirely  subsided.  About  four  weeks  after  the  attack, 
he  began  occasionally  to  discharge  a glairy  and  exceedingly 
fetid  mucus  from  the  right  nasal  cavity.  This  continued  for 
several  weeks,  when  it  nearly  ceased,  and  a similar  matter 
was  discharged  through  the  root  of  the  tooth  that  had  at  first 
caused  the  disturbance,  which  by  this  time  had  become  funnelled 
up  to  its  apex,  so  that  a probe  could  be  passed  through  it  into 
the  antrum,  from  which  cavity  the  matter  seemed  to  come.  To 
prevent  the  matter  from  discharging  itself  continually  into  his  mouth 
he  kept  the  canal  in  the  root  plugged  with  raw  cotton,  which  he 
removed  two  or  three  times  a day  to  give  vent  to  the  accumu- 
lations of  purulent  mucus. 

Persuaded  that  the  disease  of  the  antrum  had  resulted  from  the 
inflammation  excited  in  the  alveolus  of  the  second  bicuspis  by  the 
decayed  root  that  was  in  it,  and  the  abscess  that  had  in  conse- 
quence formed  and  discharged  itself  into  the  sinus,  the  indication 
of  cure,  was  too  obvious  to  be  mistaken.  It  consisted  in  the  re- 
moval of  this  local  irritant,  and  to  this  operation  he  readily 
and  at  once  submitted.  The  muco-purulent  discharge  without 
other  treatment,  soon  ceased,  the  opening  through  the  alveolus 
closed  in  about  ten  days,  and  he  has  since  remained  well. 

In  the  foregoing  case,  the  cure  was  effected  without  the  use  of 
injections  of  any  kind,  and  simply  by  the  removal  of  the  root  of 
one  tooth,  the  second  bicuspis,  which  had  caused  the  disease. 

• The  particulars  of  the  following  case  are  obtained  from  “Ob- 
servations of  Bordenave  on  the  Diseases  of  the  Maxillary  Sinus,1 ”* 
a paper  embodying  reports  of  forty  highly  interesting  cases. 

* Mem.  de  l’Acad.  Royale  de  Chirurg.  vol.  xii.  obs.  3,  p.  10. 


SECRETIONS  AND  ENGORGEMENT.  61 

Case  VI. — “In  1756,”  says  our  author,  “I  was  consulted  by  a 
lady  whose  right  cheek  was  tumefied.  About  a month  previous 
she  had  experienced  acute  pain  under  the  orbit  of  the  affected 
side ; and  she  had  felt  a pulsation  and  heat  in  the  interior  of  the 
sinus,  and  the  maxillary  bone  was  slightly  elevated.  These 
signs  determined  me  to  propose  the  extraction  of  the  third  molar 
tooth,*  and  the  perforation  of  the  antrum  through  the  alveolus. 
The  operation  was  followed  by  a discharge  of  purulent  matter, 
the  sinus  was  afterwards  injected,  the  maxilla  gradually  reduced 
itself,  and  a cure  was  effected  in  about  two  months.” 

Although  injections  were  employed  in  the  above  case,  it  was 
no  doubt  to  the  giving  of  vent  to  the  matter  contained  in  the  an- 
trum that  the  cure  was  attributable.  As  it  regards  the  cause  that 
gave  rise  to  the  affection  in  the  first  instance,  not  a single  word 
is  said.  It  might  have  resulted  from  inflammation,  lighted  up  in  the 
sockets  of  one  or  more  teeth,  and  propagated  from  thence  to  the 
mucous  membrane  of  this  cavity,  or  from  inflammation  here,  pro- 
duced by  some  other  cause,  and  a consequent  obliteration  of  the 
nasal  opening. 

The  following  brief  statement  is  taken  from  the  history  of  a 
case  narrated  by  Fauchard.f 

Case  VII.— The  child  of  M. 
first  right  superior  molaris  was  decayed,  had  a tumour  situated 
anteriorly  upon  the  upper  jaw  of  the  same  side,  extending  up  to 
the  orbit.  M.  Fauchard,  supposing  this  tumour,  which  was  about 
the  size  of  a small  egg,  had  been  caused  by  the  carious  tooth  in 
question,  determined  on  its  extraction  as  the  only  means  of  ac- 

* The  bicuspides  are  called  by  most  French  writers,  molares,  and  by  the 
“third  molar  tooth,”  he  means  the  one  which  we  call  the  first. 

|Le  Chirurgien  Dentiste,  tom.  i.  obsv.  8,  p.  483. 


Ga 


alois,  set.  twelve  years,  whose 


62 


OP  A PURULENT  CONDITION  OF  ITS 


complishing  a speedy  and  certain  cure,  and  the  result  proved  his 
opinion  to  have  been  correct.  The  removal  of  the  tooth  was  fol- 
lowed by  a large  quantity  of  yellow  serous  matter,  which  on  ex- 
amination was  found  to  have  escaped  from  the  antrum.  The 
tumour  disappeared  soon  after  the  discharge  of  the  matter,  and 
a complete  cure  was  effected. 

Bordenave,  in  noticing  the  foregoing  case,  inclines  to  doubt  that 
the  tumour  communicated  with  the  maxillary  sinus,  for  the  reason 
that  the  matter  escaped  through  the  alveolus  of  the  first  molaris 
immediately  after  its  extraction.  He,  however,  admits  that  the 
acumen  and  knowledge  of  Fauchard,  are  such  as  to  have  pre- 
vented deception  in  the  case.*  Admitting  then  the  statement  to  be 
correct,  and  surely  the  circumstance  mentioned  by  Bordenave  does 
not  in  the  least  tend  to  invalidate  it,  for  it  is  of  frequent  occurrence, 
a cure  is  effected  simply  by  the  removal  of  a decayed  tooth,  to 
the  irritation  produced  by  which,  the  disease  was  undeniably 
attributable.  The  two  following  cases  are  described  at  length  by 
the  last  named  author  in  the  “Memoirs  de  l’Academie  Royale  de 
Chirurgie.”f 

Case  VIII. — A woman  in  1731,  had  the  first  superior  molaris, 
the  crown  of  which  had  been  destroyed  by  caries,  extracted. 
Not  many  days  after  the  operation,  she  was  attacked  with  a pain 
in  the  upper  jaw  that  extended  from  the  maxillary  fossae  to  the 
orbit.  The  pain  was  so  great  as  to  deprive  her  of  rest,  but  there 
was  no  tumefaction  of  the  cheek  or  gums.  An  opening  through 
the  alveolus  into  the  sinus  was  discovered,  and  into  which  a probe 
was  introduced  by  a surgeon.  The  withdrawal  of  this  was  fol- 

* Vide,  Mem.  de  l’Acad.  Royale  Chirurg.  vol.  xii.  p.  13. 

t Vide,  vol.  xii.  12mo.  observations  5 and  6,  pages  12  and  19. 


SECRETIONS  AND  ENGORGEMENT. 


63 


lowed  by  a discharge  of  yellow  fetid  matter.  M.  Lamorier,  who 
was  afterwards  consulted,  removed  from  the  opening  a tooth 
that  had  been  thrust  into  the  antrum  and  prevented  the  egress  of 
the  matter,  which  by  its  retention  had  become  purulent.  Injec- 
tions were  employed,  and  a part  of  which,  at  the  expiration  of 
thirty  days,  escaped  from  the  nasal  opening.  A perfect  cure  was 
soon  after  effected. 

In  this  case,  the  affection  of  the  sinus,  was  evidently  the  result 
of  the  injury  inflicted  upon  the  socket  of  the  first  superior  molaris 
in  an  attempt  at  the  extraction  of  the  tooth.  Inflammation  was 
excited  by  this  and  the  presence  of  the  tooth  that  had  been  thrust 
into  the  antrum,  which  extended  itself  to  the  lining  membrane  of 
this  cavity,  and  caused  a temporary  obliteration  of  the  nasal  open- 
ing, so  that  to  effect  a cure  it  was  necessary  to  obtain  free  vent 
for  the  retained  matter.  In  restoring  a healthy  action  to  the 
mueous  membrane  of  the  cavity,  the  injections  may  have  been 
serviceable. 

Case  IX. — A girl,  set.  twenty-six  years,  in  having  a decayed 
and  painful  superior  dens  sapientise  on  the  right  side  extracted, 
the  tooth  was  broken  and  all  the  roots  but  one  were  left  in  their 
sockets.  These  caused  an  abscess  to  form,  and  this  was  followed, 
for  a short  time,  by  a subsidence  of  the  pain  ; which  however  soon 
returned,  and  a dull  heavy  sensation  was  felt  in  the  antrum  of  the 
affected  side.  From  thence  the  pain  extended  to  the  eye  and 
ear.  The  gums  at  length  became  tumefied,  and  the  pain  less 
constant ; but  the  patient,  although  five  teeth  were  in  the  mean- 
time extracted,  remained  in  this  condition  for  five  years.  At  this 
time,  1756,  M.  Beaupreau,  who  was  consulted,  found  on  exami- 
nation, that  the  gums  where  the  first  tooth  had  been  extracted, 


64 


OP  A PURULENT  CONDITION  OF  ITS 


had  not  entirely  united  and  that  a small  tubercle  had  formed  here 
from  which  a fluid  of  a bad  smell  and  reddish  colour  was  dis- 
charging itself.  He  introduced  a probe  into  the  fistulous  hole  of 
the  tubercle,  which  after  having  overcome  some  obstacle  that 
at  first  impeded  its  passage,  penetrated  the  antrum.  The  open- 
ing was  enlarged  and  mercurial  water  applied  to  the  carious 
bone,  but  it  soon  closed  and  the  pain  which  had  ceased  returned. 
Injections  were  resorted  to.  These  discharged  themselves  in 
part  through  the  nasal  opening,  and  the  patient  continued  in  this 
way  until  an  exfoliation  of  the  bone  took  place,  when  a cure  was 
at  once  effected. 

The  cause  of  the  disease  in  this,  as  in  the  preceding  cases,  was 
alveolo-dental  irritation,  and  a cure,  would  at  once  have  been 
accomplished  by  the  removal  of  the  roots  of  the  tooth  that  had 
been  left  in  their  sockets,  as  was  proven  by  the  fact,  that  it  was 
not  until  they  were  thrown  off  with  their  exfoliated  alveoli,  that 
it  was  effected. 

In  alluding  to  these  and  similar  cases,  Bordenave  concludes 
that  there  are  not  many  cases  where  the  extraction  of  teeth  simply, 
will  suffice  to  effect  a cure.  The  inference,  to  say  the  least  of  it, 
is  unfair,  for  in  the  case  last  given,  it  was  to  the  presence  of  the 
roots  of  a tooth,  that  had  been  fractured  in  an  attempt  to  extract 
it,  and  left  in  their  sockets,  that  the  affection  was  attributable, 
and  we  have  every  reason  to  believe,  that  the  cure  was  wholly 
owing  to  their  removal. 

The  history  of  the  following  exceedingly  interesting  case,  which 
was  communicated  to  the  Faculty  of  Medicine,  by  Professor 
Dubois,  is  contained  in  the  8th  number  of  their  bulletin,  for  the 
year  13,  and  also  in  Boyer’s  works  on  Surgical  Diseases. 


SECRETIONS  AND  ENGORGEMENT. 


65 


Case  X. — Upon  a child  between  seven  and  eight  years  old,  at 
the  base  of  the  ascending  apophysis  of  the  superior  maxillary 
bone,  a small  hard  round  tumour  of  the  size  of  a walnut,  was 
perceived  by  its  parents.  About  a year  after,  the  child  fell  upon 
its  face  and  caused  a considerable  discharge  of  matter  from  its 
nose,  and  at  the  same  time  bruising  the  tumour.  No  other  injury 
was  produced,  and  the  tumour  did  not  increase  perceptibly  in 
size,  from  the  eighth  to  the  fifteenth  year.  During  the  next  year 
however,  it  sensibly  augmented,  and  from  the  sixteenth  to  the 
eighteenth  year,  it  attained  so  great  a volume  that  the  floor  of  the 
orbit  was  elevated,  which  caused  a diminution  in  the  size  of  the 
eye,  and  restricted  the  motions  of  the  eyelids.  The  arch  of  the 
palate  was  depressed  and  the  nasal  fossae  almost  closed.  The 
nose  was  forced  to  the  right  side  at  the  upper  part  of  the  tumour, 
and  there  was  a considerable  elevation  beneath  the  sub-orbital 
fossae.  The  skin  below  the  inferior  eyelid  was  of  a violet  red 
colour  and  very  tense.  The  upper  lip  was  elevated  and  the  gums 
on  the  left  side  protruded  beyond  those  on  the  other  side  of  the 
arch.  Respiration  was  painful,  and  the  patient  spoke  with  diffi- 
culty. Sleep  was  laborious  and  mastication  was  attended  with 
pain.  “In  this  state,”  says  M.  Boyer,  “he  was  seen  by  M. 
Dubois,  September  1st,  1802,  but  as  he  was  not  able  to  deter- 
mine on  the  proper  operation,  M.  Sabatier,  M.  Peletan  and  him- 
self were  called  in.  It  was  the  opinion  of  all,  that  there  was  a 
fungus  tumour  of  the  antrum,  and  for  the  removal  of  this  M. 
Dubois  was  requested  to  make  choice  of  his  own  method  of 
operating. 

A fluctuation  was  felt  behind  the  upper  lip,  and  this  determined 
M.  Dubois  to  commence  the  operation  by  making  an  incision  there. 

9 


66 


OF  A PURULENT  CONDITION  OF  ITS 


This  was  followed  by  a discharge  of  a large  quantity  of  a glairy 
lymphatic  substance.  Through  this  opening  a sound  was  intro- 
duced into  the  antrum,  and  to  M.  Dubois1  surprise,  this  cavity 
contained  no  tumour,  but  upon  moving  the  sound  about  it  struck 
upon  a hard  substance,  in  the  most  elevated  part  of  the  sinus, 
which,  on  being  removed  proved  to  be  a canine  tooth.  Prepara- 
tory, however,  to  its  extraction,  two  incisors  and  one  molaris 
were  removed  and  their  alveoli  cut  away.  Injections  were  after- 
wards employed  and  the  patient  was  soon  restored  to  health. 

It  is  not  necessary  to  stop  to  inquire  how  this  tooth  got  into 
the  antrum;  aberrations  of  this  sort  in  the  growth  of  the  teeth  are 
frequently  met  with,  and  some  precisely  similar  instances  have 
already  been  referred  to.# 

In  all  the  cases  which  have  as  yet  been  noticed,  the  affection 
was  traceable  to  local  irritation,  and  in  all  except  this  last,  it  had 
originated  in  the  alveolar  ridge.  But,  the  following  case  of  muco- 
purulent engorgement  may  be  thought  by  some  to  have  been 
occasioned  by  a different  cause.  Yet,  there  are  circumstances 
connected  with  the  history  of  even  this  case,  that  go  far  to  justify 
the  belief,  that  if  the  teeth  had  been  in  a healthy  condition  the 
affection  would  not  have  been  produced. 

Case  XI. — Mr.  G.  a labourer,  aet.  about  thirty,  of  a decidedly 
scorbutic  habit,  applied  in  the  spring  of  1834,  to  an  eminent 
medical  gentleman  of  this  city,  to  obtain  his  advice  concerning 
an  affection  of  the  left  side  of  his  face,  under  which  he  had  been 
labouring  for  several  months.  The  physician  to  whom  he  ap- 
plied, after  having  examined  the  case,  came  to  the  conclusion, 
that  it  was  mucous  engorgement  of  the  maxillary  sinus,  and 
# Vide  note,  on  page  46. 


SECRETIONS  AND  ENGORGEMENT. 


67 


requested  him  to  call  upon  me,  and  have  one  of  his  molar  teeth 
extracted,  and  the  floor  of  the  antrum  through  its  alveolus  pierced. 
He  at  the  same  time  desired,  that  if  his  opinion  in  regard  to  the 
nature  of  the  disease  proved  to  be  correct,  I would  take  charge 
of  the  case  altogether.  On  examining  his  mouth,  I discovered 
that  nearly  all  his  teeth  of  both  jaws,  gums  and  alveoli  were 
extensively  diseased,  and  on  inquiry  obtained  from  him  the  fol- 
lowing statement  with  regard  to  the  commencement  and  progress 
of  the  affection  of  the  antrum. 

About  six  months  previous  to  this  time,  having  been  exposed 
while  pursuing  his  ordinary  avocations,  to  very  inclement  and 
several  sudden  changes  of  weather,  he  contracted  a severe  cold  ; 
in  consequence  of  which,  he  was  confined  to  his  bed  for  several 
days;  during  this  time,  he  was  twice  bled,  took  two  cathartics, 
and  other  medicines 

The  disease  at  first  concentrated  itself  in  his  head,  face,  and 
jaws,  which  at  the  expiration  of  eight  or  ten  days,  was  subdued 
by  the  above  treatment,  with  the  exception  of  the  pain  in  his  left 
cheek,  and  soreness  in  the  superior  teeth  of  the  same  side.  The 
pain  in  his  cheek,  although  not  constant,  still  continued;  the  nasal 
cavity  of  that  side  ceased  to  be  supplied  with  its  usual  secretion, 
the  teeth  became  more  sensitive  to  the  touch,  and  finally  at  the 
end  of  four  months,  a slight  protuberance  of  the  cheek  was  ob- 
servable, accompanied  by  a tumour  upon  the  left  side  of  the  pal- 
atine arch,  which,  when  1 first  saw  him  had  attained  to  half  the 
size  of  a black  walnut,  and  it  was  by  the  fluctuation  here  felt,  that 
the  physician  whom  he  first  consulted,  was  induced  to  suspect  the 
true  nature  of  the  disease. 

Acting  under  the  direction  of  the  medical  gentleman,  under 


68 


OF  A PURULENT  CONDITION  OF  ITS 


whose  care  the  patient  had  placed  himself,  I extracted  the  second 
left  superior  molaris,  and  through  its  alveolus  penetrated  the  an- 
trum by  means  of  a straight  trocar,  and  after  the  withdrawal  of 
which,  a large  quantity  of  a glairy  fetid  mucous  fluid  was  dis- 
charged. The  perforation  was  kept  open  by  means  of  a bougie, 
secured  with  a silk  ligature  to  an  adjoining  tooth,  as  recommend- 
ed by  Deschamps,  and  the  antrum  injected  three  times  a day; 
at  first,  simply  with  rose  water,  to  which  a small  quantity  of  sul- 
phate of  zinc  was  afterwards  added.  By  this  treatment,  the 
lining  membrane  of  the  antrum  at  the  expiration  of  five  weeks 
was  restored  to  health,  and  the  secretions  that  escaped  through 
the  perforation  no  longer  exhaled  a fetid  odor. 

The  patient  not  experiencing  any  inconvenience  withdrew 
the  bougie,  and  allowed  the  aperture  to  close.  In  about  two 
months,  he  again  presented  himself  to  me,  and  was  similarly 
affected  as  when  I first  saw  him.  I now  extracted  the  first  su- 
perior left  molaris,  and  perforated  the  antrum  through  its  alveolus, 
and  a quantity  of  fetid  mucous  fluid  was  again  discharged ; the 
dens  sapiential  and  the  first  and  second  bicuspides  of  the  affected 
side,  which  were  carious,  were  also  extracted.  Injections  of 
sulphate  of  zinc  and  rose  water,  diluted  tincture  of  myrrh,  dilu- 
ted port  wine,  a decoction  of  Gallse,  were  alternately  employed 
for  three  months,  at  the  expiration  of  which  time,  the  nasal  open- 
ing which  had  been  previously  closed,  was  re-established,  and  a 
perfect  cure  was  effected. 

The  condition  of  the  teeth  in  the  case  just  narrated,  may  not 
be  thought  to  have  exerted  any  agency  in  the  production  of  the 
affection  of  the  antrum,  but  there  are  circumstances  connected 
with  its  progress  that  would  seem  to  justify  a different  conclusion. 


SECRETIONS  AND  ENGORGEMENT. 


69 


The  presence  of  the  decayed  teeth  beneath  the  sinus,  may  not 
only  have  contributed  to  aggravate  the  morbid  action  lighted  up 
in  it  by  the  cold  which  he  had  taken,  but  they  may  also  have 
caused  it  to  locate  itselfin  this  cavity  ; and  the  fact  that  the  inflam- 
mation of  its  lining  membrane  and  the  obliteration  of  the  nasal 
opening  continued  until  they  were  removed,  would  at  least,  seem 
to  warrant  such  an  inference.  That  the  injections  were  benefi- 
cial, I do  not  doubt,  but  that  the  cure  was  effected  by  them,  no 
one,  I think,  will  dare  to  affirm.  I am  far  from  believing  that 
the  presence  of  the  decayed  teeth  was  the  sole  cause  of  the  dis- 
ease in  the  antrum,  but  that  they  contributed  to,  and  protracted 
it,  I cannot  hesitate  to  believe,  and  but  for  the  increased  exci- 
tability and  perhaps  actual  inflammation,  induced  in  the  mucous 
membrane  of  this  cavity,  by  the  exposure  of  the  patient  to  incle- 
ment and  sudden  transitions  of  weather,  it  is  probable  that  the  sinus 
would  never  have  become  affected,  and  I think  it  not  unlikely,  that 
notwithstanding  the  disturbance  that  may  have  been  originated 
in  it  by  this  cause,  no  very  serious  or  lasting  morbid  effect  would 
have  been  produced,  if  the  teeth  and  alveoli  had  been  in  a per- 
fectly healthy  condition. 

A very  interesting  case  of  muco-purulent  secretion  of  the  mu- 
cous membrane  of  this  cavity,  occasioned  by  an  exostosis  of  a 
superior  molaris,  which  gave  rise  to  an  obstinate  ozena,  came 
under  the  observation  of  the  author  in  1839.  A detailed  account 
of  it,  might  very  properly  be  introduced  into  the  present  treatise, 
but  inasmuch  as  the  history  of  the  case  has  been  recently  pub- 
lished in  the  “Maryland  Medical  and  Surgical  Journal,”  the 
“Medical  Examiner,”  and  the  “American  Journal  of  Dental  Sci- 
ence,” I have  thought  it  best  to  omit  it. 


70 


OF  A PURULENT  CONDITION  OF  ITS 


The  particulars  of  the  following  highly  interesting  case  were 
communicated  to  me  by  Dr.  L.  Roper,  an  eminent  dentist  of 
Philadelphia,  in  a conversation  which  I had  with  him  about  six 
months  since. 

Casf,  XII. — Miss  M , a young  lady  from  the  West  Indies, 

of  about  fourteen  years  of  age,  had  a fistulous  opening  beneath 
the  right  orbit,  that  communicated  with  the  maxillary  sinus.  By 
means  of  a probe  introduced  through  the  opening  into  this  cavity, 
the  apices  of  the  roots  of  the  first  superior  molaris  could  be  dis- 
tinctly felt. 

Medical  aid  was  sought  at  an  early  stage  of  the  disease,  but 
as  no  permanent  benefit  resulted  from  the  treatment  adopted,  the 
young  lady,  at  the  expiration  of  nine  months,  was  brought  by  her 
father  to  Philadelphia,  and  in  the  spring  of  1831,  placed  under  the 
care  of  the  late  Dr.  Physick;  who,  suspecting  that  the  affection  of 
the  antrum  had  resulted  from,  and  was  still  kept  up  by  irritation 
produced  by  the  first  superior  molaris  of  the  affected  side,  which 
was  considerably  decayed,  directed  her  to  be  taken  to  Dr.  Roper, 
who,  concurring  with  him  in  opinion,  at  once  extracted  the  carious 
tooth.  The  operation  was  followed  by  the  immediate  discharge 
of  a large  quantity  of  thick,  muddy,  and  greenish  matter.  The 
fistula  under  the  orbit  soon  closed,  and  without  further  treatment 
a perfect  cure  was  accomplished  in  the  course  of  a few  weeks. 

The  foregoing  are  all  Ihe  particulars  which  I could  obtain  con- 
cerning this  interesting  case ; but  I have  no  doubt  that,  if  all  the 
circumstances  connected  with  its  early  history  were  known,  it 
would  be  found  to  have  resulted  from  inflammation  of  the  lining 
membrane  of  the  antrum,  caused  by  irritation  in  the  socket  of  the 
tooth  that  was  extracted;  and  this  opinion  is  sustained  by  the 


SECRETIONS  AND  ENGORGEMENT. 


71 


facts,  that  this  tooth  was  affected  with  caries,  and  that  its  removal 
was  followed  by  an  immediate  cure  of  the  disease. 

In  Bordenave’s  collection  of  cases  of  disease  of  the  maxillary 
sinus,  published  in  the  Memoirs  of  the  Royal  Academy  of  Sur- 
gery,* there  are  several  cases  similar  to  the  one  just  narrated.  I 
subjoin  a description  of  the  two  following. 

Case  XIII. — A servant  of  the  Count  of  Maurepes  had  been 
afflicted  for  six  months  with  a fistula  upon  the  left  cheek,  a little 
below  the  orbit,  which  penetrated  the  maxillary  sinus,  caused  by 
the  spontaneous  opening  of  an  abscess.  The  third  and  fourth  mo- 
lares,  (which  are  the  first  and  second  according  as  the  teeth  are 
now  designated,)  both  of  which  were  considerably  decayed,  were 
extracted  by  M.  Hevin,  but  as  there  were  no  openings  through 
the  alveoli,  he  perforated  one  with  a trocar ; this  opening  gave 
vent  to  a great  quantity  of  putrid  sanies,  and  it  did  not  close  for 
more  than  a year  after  it  was  made,  but  the  fistula  of  the  cheek 
healed  in  about  ten  days. 

Case  XIV. — In  1717,  a soldier  of  the  regiment  of  Bassigny, 
who  had  for  a long  time  a fistula  in  his  cheek  penetrating  into  the 
maxillary  sinus,  was  treated  for  it  at  the  Hotel  Dieu,  of  Mont- 
pelier. The  matter  settling  near  the  orifice  of  the  fistula,  pre- 
vented it  from  closing.  M.  Lamourier,  on  examining  the  mouth 
of  the  soldier,  perceived  that  the  second  superior  molaris  was 
decayed ; this  he  extracted  and  profited  by  the  alveolar  cavity, 
in  opening  the  base  of  the  sinus.  The  fistula  of  the  cheek  was  by 
this  means  cured  in  a few  days,  but  the  counter  opening  was  not 
immediately  permitted  to  close. 

* Vide  Observations  vii.  via.  xii.  and  xiii.  vol,  12;  12mo.  ed.  pages  26,  33 
and  34. 


72 


OP  A PURULENT  CONDITION,  &C. 


In  cases  of  fistula  resulting  simply  from  engorgement  of  the 
sinus,  the  treatment,  as  has  been  shown  by  the  result  of  that  in 
the  foregoing  cases,  consists  in  the  formation  of  a counter  open- 
ing, which  should  always  be  effected  at  the  most  dependent  part 
of  the  cavity,  and  in  the  removal  of  all  sources  of  local  irritation. 
Injections  should  also  be  employed. 

In  the  cases  that  have  thus  far  been  presented,  I have  selected 
such  as  were  not  complicated  with  abscesses,  ulceration  of  the 
lining  membrane,  or  caries  of  the  surrounding  osseous  walls ; but 
to  the  existence  of  the  two  last,  the  affections  on  which  I have 
just  been  treating,  often  give  rise.  But  I will  not  extend  my  re- 
marks further  upon  mucous  engorgement  and  a purulent  condi- 
tion of  the  secretions  of  this  cavity.  The  next  form  of  disease  on 
which  I propose  to  speak,  is  abscess — an  affection,  differing  in 
all  its  characteristics  from  those  that  have  thus  far  been  treated  on. 


CHAPTER  IV. 


OF  ABSCESS . 

Abscess  in  the  maxillary  sinus,  although  very  rare,  does,  not- 
withstanding, sometimes  happen.  The  structure  of  the  parts 
composing  this  cavity,  would  seem,  as  has  been  remarked  by 
Mr.  Bell,  to  render  the  occurrence  improbable,  and  if  the  fact 
were  not  well  established,  it  might  perhaps  be  doubted.  If 
the  apices  of  the  roots  of  some  of  the  superior  molares  did  not 
occasionally  perforate  the  floor  of  this  cavity,  the  occurrence  of 
abscess  in  it  would  indeed  be  rare,  but,  as  the  antrum  is  some- 
times thus  penetrated,  its  formation  here  is  not,  after  all,  a matter 
of  so  much  surprise.  An  abscess  is  just  as  liable  to  form  at  the 
apex  of  the  root  of  a tooth  penetrating  this  cavity,  as  at  that  of 
one  in  its  alveolus,  but  it  is  very  seldom  that  one  is  found  seated 
in  any  other  place  in  it.  The  case  described  by  Mr.  Bell  is  sup- 
posed to  be  the  only  well  authenticated  one  on  record.  Borde- 

_ v 

nave,  however,  gives  the  history  of  a case  of  disease  of  the  max- 
illary sinus,*  which  at  the  time  of  my  previous  allusion  to  the 
abscess  of  this  cavity  described  by  Mr.  B.,  had  escaped  my  recol- 
lection, so  similar  to  this,  that  there  can  be  little  doubt  in  regard 
to  the  nature  of  the  disease.  In  both  instances,  the  affection  was 
seated  in  the  upper  part  of  the  antrum  beneath  the  orbit.  But,  it 
is  unnecessary  to  say  more  at  present  concerning  these  cases,  as 
I intend  in  the  proper  place,  to  give  a description  of  them. 

* Vide  Mem.  dePAcad,  Roy  ale  de  Chirurg.  vol.  12,  ed.  12mo.  obs.  xi.  p.  31 , 

10 


74 


OF  ABSCESS. 


Mr.  Hullihen,  in  a well  written  article  in  the  “American  Jour- 
nal of  Dental  Science, contends  that  abscess  of  the  antrum  as 
well  as  alveolar,  consists  in  the  effusion  of  pus,  formed  in  the 
pulp  cavity  of  a tooth,  “between  the  bone  and  lining  membrane.” 
That  this  view  of  the  subject  is  incorrect,  is  proven  by  the  fact 
that  abscesses  are  as  frequently  formed  in  the  sockets  of  dead 
teeth  as  living  ones.  The  matter  from  alveolar  abscess  in  those 
cases  where  the  plate  of  bone  intervening  between  the  extremity 
of  the  root  or  roots  of  a superior  molaris  or  bicuspis,  as  the  case 
may  be,  is  thinner  than  the  osseous  walls  surrounding  it  or  them, 
often  escapes  through  it  into  this  cavity,  after  having  first,  as  Mr. 
H.  justly  remarks,  effused  itself  between  the  bone  and  lining 
membrane.  But  in  this  case,  it  cannot  properly  be  termed  an 
abscess  of  the  antrum.  Although  the  matter  escapes  into  this 
cavity,  and  it,  in  consequence  becomes  involved  in  disease,  yet 
the  disease  having  originated  in  the  alveolus  of  a tooth,  which  is 
still  its  principal  seat,  it  is,  in  the  strictest  sense  of  the  term,  an 
alveolar  abscess.  It  not  unfrequently  happens  that  the  pus  from 
an  abscess  formed  in  the  socket  of  a superior  molaris,  discharges 
itself  into  this  cavity  and  escapes  through  the  nasal  opening  for 
months  and  sometimes  for  years,  for,  after  an  abscess  has  once 
formed  at  the  apex  of  the  root  of  a tooth,  purulent  matter  will 
continue  to  be  formed,  though  not  always  in  the  same  quantity 
until  the  irritant  that  caused  it  is  removed.  The  pulp,  or  gan- 
glion as  some  French  writers  term  it,  may  suppurate,  and  the  mat- 
ter be  confined  in  the  cavity  of  the  tooth  for  a long  time  without 
causing  alveolar  abscess,  and  the  purulent  matter  contained  in  the 
sac  at  the  extremity  of  the  root  of  a tooth,  is  not  formed,  as  Mr. 


| Vide  vol.  ii.  page  179. 


OF  ABSCESS, 


75 


H-  supposes,  in  the  cavity  of  the  organ.  The  alveolo-denta! 
membranes  at  the  apex  of  the  root  of  a tooth  around  the  nerve 
cord,  are  more  vascular  and  are  endowed  with  greater  nervous 
sensibility,  than  at  any  other  part,  consequently  the  inflammatory 
action  here  is  always  the  greatest,  and  it  is  here  that  suppuration 
first  takes  place. 

The  apices  of  the  roots  of  the  first  and  second  superior  molares, 
when  they  do  not  actually  perforate  the  floor  of  the  antrum,  are 
often  above  its  level,  and  covered  by  only  a very  thin  shell  or 
cap  of  bone,  and  hence  in  case  of  an  abscess  in  one  of  these, 
although  strictly  alveolar,  the  matter  is  more  liable  to  make  for  itself 
a passage  into  this  cavity,  than  through  the  gum  into  the  mouth. 
When  this  happens,  it  gives  rise  to  inflammation  of  the  lining 
membrane  and  causes  its  secretions  to  become  more  or  less 
vitiated,  and  often  leads  to  an  erroneous  opinion  concerning  the 
real  nature  of  the  disease. 

But  it  is  only  when  the  root  of  a tooth  actually  penetrates  the 
floor  of  the  antrum,  or  the  tubercle  at  its  apex  becomes  situated 
in  it,  that  the  abscess  can  properly  be  said  to  be  of  this  cavity. 
And  when  the  root  of  the  tooth  does  penetrate  it,  the  tubercle, 
although  formed  at  its  apex  around  the  nerve  cord,  as  it  is  com- 
monly called,  is  between  the  lining  membrane  and  periostea!  tis- 
sue, both  of  which,  in  the  immediate  vicinity  become  directly 
and  at  once  involved  in  the  inflammation  here  lighted  up,  and 
this  sometimes  extends  itself  to  every  part  of  the  cavity,  causing 
in  some  instances,  an  obliteration  of  the  nasal  opening.  This 
however,  does  not  often  occur,  but  when  it  does,  it  is  followed 
by  engorgement  of  the  sinus,  and  occasionally,  by  ulceration  of 
its  lining  membrane,  and  disease  in  the  surrounding  bone. 


76 


OP  ABSCESS. 


It  is  sometimes  the  case,  that  the  plate  of  bone  intervening 
between  the  extremity  of  the  root  of  a tooth,  around  which  a 
tubercle  has  formed,  and  the  antrum,  is  destroyed,  and  the  tuber- 
cle, instead  of  being  wholly  confined  within  the  alveolus,  is  furced 
up,  as  it  enlarges,  almost  entirely  into  this  cavity.  The  inflam- 
mation after  having  attained  a certain  height,  is  succeeded  by 
suppuration,  and  the  secretion  of  pus  goes  on  until  the  sac  bursts, 
when  the  matter  is  discharged,  and,  mixing  with  the  mucous 
secretions  of  this  cavity,  ultimately  escapes  with  them  through 
the  nasal  opening,  if  it  be  not  closed,  into  the  nose. 

As  it  regards  the  morbid  effects  produced  upon  the  lining  mem- 
brane and  surrounding  bony  parietes  of  the  antrum,  by  an  abscess 
of  this  kind,  it  is  of  little  consequence  whether  it  be  formed  in  it, 
if  the  matter  be  discharged  there,  or  in  the  alveolus  of  the  tooth 
that  gave  rise  to  it.  The  effects  are  about  the  same  in  one  case 
as  in  the  other.  If  the  general  health  of  the  patient  be  good,  and 
the  natural  opening  of  the  sinus  remains  pervious,  they  seldom  as- 
sume an  alarming  character,  but  under  other  and  less  favourable 
circumstances,  the  most  dangerous  and  aggravated  forms  of  disease 
to  which  this  cavity  is  liable,  may  result  from  an  abscess  seated 
in  either  place. 

Symptoms. — In  the  incipient  or  forming  stages  of  abscess  of  the 
maxillary  sinus,  the  symptoms  are  similar  to  those  that  characte- 
rize inflammation  of  the  lining  membrane  of  this  cavity,  or  violent 
inflammatory  tooth-ache.  The  pain  is  generally  most  severe  in 
the  upper  part  of  the  alveolar  ridge,  above  some  one  of  the  molar 
or  bicuspid  teeth.  From  thence,  it  often  extends  to  the  lower  part 
of  the  orbit,  ear,  temple,  muscles  of  the  cheek  and  scalp.  It  is 
more  or  less  constant,  and  a throbbing  is  felt  high  up  in  the  alve- 


OP  ABSCESS. 


77 


olar  border  beneath  the  cheek.  If  the  abscess  originated  at  the 
apex  of  the  root  of  a tooth,  this  organ  will  appear  slightly  elon- 
gated and  sore  to  the  touch ; the  cheek  in  most  instances  is  a little 
tumefied  and  more  or  less  flushed. 

The  pain  after  having  continued  for  several  days,  is  succeeded 
by  suppuration,  when  it  immediately  subsides.  Slight  paroxysms 
of  cold  and  heat  are  now  felt,  and  if  the  natural  opening  of  the 
antrum  be  not  closed,  purulent  matter  will  occasionally  be  dis- 
charged. 

If  the  abscess  be  seated  in  any  other  part  than  the  base  of  the 
antrum,  the  symptoms  may  differ  in  some  respects  from  the  fore- 
going. But  if  purulent  matter,  or  mucus  mixed  with  pus  be  dis- 
charged from  the  nostril  of  the  affected  side,  when  the  patient 
inclines  his  head  to  the  opposite  one,  or  makes  a sudden  and 
forcible  expiration  through  it,  while  the  other  is  closed,  the  exis- 
tence of  abscess  in  this  cavity,  will  be  very  conclusively  indicated. 

The  abscess  having  burst,  pus  will  be  discharged  from  it,  from 
time  to  time,  for  several  days,  which  will  escape  through  the 
nasal  opening,  except  this  passage  has  become  closed  or  choked 
up  with  hardened  floculi  or  other  foreign  matter,  and  then  it  will 
cease  altogether,  or  very  nearly  so.  The  disease  however,  if  the 
irritant  that  gave  rise  to  it  still  remains,  is  by  no  means  cured. 
A recurrence  of  it  generally  takes  place,  every  time  the  patient 
takes  cold,  when  all  the  symptoms  just  described  will  be  again 
experienced,  and  each  succeeding  attack  leaves  the  parts  implica- 
ted in  the  morbid  diathesis  thus  lighted  up,  in  a more  unhealthy 
condition,  and  as  a consequence  more  susceptible  of  being  acted 
upon  by  morbid  irritants.  Suppuration  also,  at  each  successive 
attack  takes  place,  and  the  pus  gradually  assumes  a worse  cha- 
racter. 


78 


OP  ABSCESS. 


Causes. — It  will  not  be  necessary  to  say  much  concerning  the 
causes  of  abscess  of  the  antrum.  It  will  be  sufficient  to  state, 
that  they  are  the  same  as  those  of  tooth-ache,  inflammation  of  the 
alveolo-dental  periostea  and  inflammation  of  the  lining  membrane 
of  this  cavity,  and  it  is  to  the  presence  of  one  or  other,  or  both  of 
these  that  it  is  attributable.  And  these  may  be  excited,  by  caries 
of  the  teeth,  a blow  upon  them,  or  a dead  or  loose  tooth,  or  a blow 
upon  the  cheek  and  by  exposure  to  sudden  changes  of  weather, 
as  from  heat  to  cold,  &c.  Other  causes  may  sometimes  be  con- 
cerned, but  the  foregoing  are  the  principal,  and  all  that  it  is  neces- 
sary to  enumerate  here. 

Treatment. — In  the  cure  of  abscess  of  the  maxillary  sinus,  as 
as  well  as  that  of  a muco-purulent  condition  of  its  secretions  or  en- 
gorgement, the  first  and  most  important  indication  to  be  fulfilled, 
is  to  obtain  a vent  for  the  matter,  from  the  inferior  part  of  the 
cavity.  The  best  method  of  doing  this  has  before  been  described, 
and  it  is  unnecessary  to  recapitulate  the  directions  that  have 
already  been  given  for  the  accomplishment  of  this  object. 

The  formation  of  abscess  in  this  cavity  might  however,  in  al- 
most every  instance  be  prevented,  by  the  timely  adoption  of  pro- 
per treatment.  On  the  occurrence  of  severe,  deep-seated  and 
throbbing  pain  in  the  upper  part,  of  the  the  alveolar  ridge  or  just 
above  it  in  the  region  of  the  antrum,  such  as  has  been  described  as 
attending  the  formation  of  abscess  in  this  cavity  or  in  that  of  the 
alveolus  of  a superior  molaris,  or  if  the  tooth  directly  beneath  the 
place  where  it  was  first  felt,  be  considerably  decayed,  or  its  lining 
membrane  exposed,  or  if  it  be  dead,  loose,  or  its  socket  much  dis- 
eased, it  should  be  immediately  extracted.  By  this  simple  opera- 
tion, the  formation  of  abscess  not  only  in  the  socket  of  the  tooth,  but 


OF  ABSCESS. 


79 


also  in  the  antrum,  may,  in  almost  every  instance  be  prevented.  If 
however,  it  be  not  followed  by  an  immediate  subsidence  of  pain, 
leeches  should  be  applied  to  the  gums  and  fomentations  to  the 
cheek.  If  the  patient  be  of  a full  habit,  and  if  there  be  any  gene- 
ral febrile  symptoms,  saline  purgatives  may  also  be  employed  with 
advantage.  But  in  the  majority  of  cases,  the  extraction  of  the 
tooth  will  be  all  that  is  required  to  arrest  the  progress  of  the 
disease. 

The  curative  indications,  if  the  abscess  be  of  recent  formation, 
and  has  resulted  from  the  presence  of  a diseased  tooth,  are  simi- 
lar to  the  preventive,  The  first  thing  to  be  done  is  to  remove 
the  tooth  that  caused  it,  and  if  this  operation  be  not  delayed  too 
long,  it,  in  most  instances  will  be  all  that  is  necessary  to  effect  a 
cure.  In  addition  to  this,  Mr.  Hullihen  recommends  the  perfora- 
tion of  the  antrum  but  in  those  cases  where  the  abscess  has 
formed  at  the  apex  of  the  root  of  a molaris,  this  is  not  necessary, 
because  in  all  such  cases,  the  alveolus  communicates  with  this 
cavity,  so  that  on  the  removal  of  the  tooth,  there  will  be  a suffi- 
ciently large  opening  into  it;  and  besides,  the  tubercle  or  sac 
although  situated  within  the  sinus,  is  in  nearly  every  instance 
brought  away  with  the  tooth. 

But,  when  the  abscess  has  been  of  long  standing,  and  the  lining 
membrane  of  the  antrum  become  seriously  affected,  in  addition  to 
the  removal  of  the  tooth,  other  treatment  will  have  to  be  resorted 
to.  The  opening  into  the  antrum,  if  necessary,  should  be  enlarged, 
and  it  should  be  prevented  from  closing  until  the  health  of  the  lining 
membrane  is  restored;  and  for  the  promotion  of  this,  injections, 
such  as  have  been  previously  recommended,!  will  be  found  ser- 
viceable. 

* American  Journal  of  Denial  Science,  vol.  ii.  p.  182. 

t Vide  page  57. 


80 


OF  ABSCESS. 


In  cases  of  simple  abscess  of  the  antrum,  seated  at  the  apex  of 
the  root  of  a superior  rnolaris,  I have  never  found  it  necessary  to 
adopt  other  treatment  than  the  foregoing.  It  may,  however,  in 
some  instances,  be  necessary  to  remove  more  than  one  tooth, 
even  though  that  be  the  one  that  gave  rise  to  the  abscess.  The 
following  case  presents  an  example  of  this  kind. 

Case  XV. — Miss  E.  M — , set.  seventeen,  of  a scrofulous  habit, 
was  placed  under  my  care  in  the  spring  of  1837,  for  the  purpose 
of  obtaining  relief  from  a severe  deep-seated  pain  in  her  right 
cheek,  apparently  a little  above  the  first  superior  rnolaris,  and 
which  was  supposed  to  result  from  a diseased  condition  of  several 
teeth  on  that  side  of  the  upper  maxillary.  The  pain,  although 
very  severe,  seldom  lasted  more  than  three  or  four  days.  She 
had  experienced  several  attacks  of  it, — the  first  about  eighteen 
months  before  I saw  her,  and  its  subsidence,  every  time,  was  fol- 
lowed by  occasional  discharges  of  purulent  matter  from  the  nostril 
of  the  affected  side.  These  discharges,  at  first,  continued  only  for 
three  or  four  days,  but  they  lasted  longer  after  each  successive 
attack,  and  became  more  acrid  and  offensive. 

Three  days  previously  to  my  seeing  her  she  had  had  an  attack, 
and  the  inflammation  at  the  time  had  nearly  reached  a crisis.  Her 
cheek  was  slightly  swollen  and  considerably  flushed,  and  an 
exceedingly  painful  throbbing  sensation  was  felt  in  the  region  of 
the  malar  apophysis.  I directed  four  leeches  to  be  applied  to  the 
gum  covering  the  lower  part  of  this,  beneath  the  cheek,  fomenta- 
tions to  the  face,  and  pediluvium  before  going  to  bed.  These,  I 
was  informed,  had  been  prescribed  in  preceding  attacks,  and  that 
only  very  temporary  benefit  had  been  obtained  from  them,  I,  in 
consequence,  contented  myself,  knowing  that  the  inflammation 


OP  ABSCESS. 


81 


would  soon  run  its  course,  by  advising  the  application  of  anodyne 
fomentations  to  the  face. 

The  next  day  I saw  her,  and  the  pain  had  nearly  subsided,  but 
there  was  considerable  inflammation  and  sponginess  in  the  gums 
around  the  superior  bicuspid  and  molar  teeth.  The  first  molaris 
was  very  sensitive  to  the  touch.  The  morning  of  the  second  day 
after  I saw  her,  matter  resembling  pus,  and  of  a fetid  odor,  was 
discharged  from  the  nose.  Believing  that  this  came  from  an 
abscess  in  the  antrum,  caused  by  the  presence  of  the  first  superior 
molaris,  I advised  its  immediate  removal,  to  which,  after  con- 
siderable persuasion,  she  submitted.  As  I had  suspected,  this 
proved  to  be  the  tooth  which  had  occasioned  the  mischief.  At 
the  extremity  of  its  two  outer  fangs,  which  were  almost  in  contact, 
was  a tubercle  the  size  of  a large  pea,  and  there  was  an  opening 
into  the  antrum  through  which  a small  goosequill  could  be  passed. 
A considerable  quantity  of  bloody  mucous  matter  streaked  with 
pus,  immediately  escaped  from  it.  The  importance  of  having 
several  other  decayed  teeth  removed,  was  urged,  though  not  as 
necessary  to  the  cure  of  the  affection  to  which  she  had  been  sub- 
ject, but  she  would  not  submit  to  the  operation. 

Three  weeks  after  the  extraction  of  the  tooth,  I again  saw  her, 
and  was  informed  that  she  had  not  since  experienced  any  pain;  the 
alveolus  had  closed,  but  a glairy  fetid  matter  was  occasionally 
discharged  from  her  right  nostril.  The  alveolus  was  re-opened  by 
cutting  away  the  fleshy  granulations  that  had  filled  it,  and  a small 
quantity  of  matter  such  as  I have  just  described,  came  away.  In- 
jections were  now  employed  of  diluted  tincture  of  myrrh  and  rose 
water  with  a small  quantity  of  sulphate  of  zinc.  The  opening  was 
prevented  from  closing,  and  the  use  of  the  injections  persisted  in  for 
11 


82 


OF  ABSCESS. 


three  or  four  weeks,  when  the  bougie  that  had  been  inserted  in  the 
alveolus  to  prevent  it  from  filling  up,  was  left  out.  The  opening 
soon  closed,  and  in  the  course  of  ten  or  twelve  days,  a glairy  fetid 
matter  was  again  occasionally  discharged  from  the  nostril  of  the 
affected  side,  and  again  a vent  was  procured  for  it  through  the 
socket  of  the  tooth  that  had  been  extracted.  This  was  now  kept 
open  for  five  or  six  weeks,  when  it  for  the  third  time  was  permit- 
ted to  close,  and  for  two  weeks  there  were  no  signs  of  a return  of 
the  discharge  of  fetid  glairy  mucus  from  the  nostril;  but  at  the 
expiration  of  fifteen  or  sixteen  days  it  became  apparent  that  the 
mucous  membrane  of  the  antrum  was  not  restored  ; its  secretions 
again  became  fetid.  Suspecting  that  the  diseased  condition  of  the 
teeth,  gutns,  and  alveolar  processes  beneath  the  cavity  exerted  a 
morbid  influence  upon  it,  I,  a second  time,  urged  the  removal  of 
the  first  bicuspis,  and  the  second  and  third  molares,  which  were 
all  so  much  decayed  as  to  render  their  restoration  out  of  the  ques- 
tion. With  much  persuasion  the  consent  of  the  patient  was  ob- 
tained, and  the  teeth  were  at  once  extracted. 

Four  weeks  after,  the  secretions  of  the  antrum  had  become 
healthy,  and  they  have  since  remained  so. 

The  morbid  condition  of  the  mucous  membrane  ol  the  antrum, 
although  in  this  case  it  had  no  doubt  resulted  from  the  abscess 
that  had  formed  at  the  apices  of  two  of  the  roots  of  the  tooth  first 
extracted,  was  subsequently  kept  up,  by  the  irritation  of  the 
alveolo  dental  membranes,  occasioned  by  the  other  decayed 
teeth. 

Before  I conclude  my  remarks  upon  abscess  of  this  cavity,  I 
will  give  the  history  of  the  two  cases  to  which  allusion  has  before 
been  made,  the  one  is  narrated  by  Mr.  Thomas  Bell,*  and  the 
* Anal.  Phys.  of  the  Teeth,  and  Diseases  p.  270. 


OP  ABSCESS. 


83 


other  by  Bordenave.*  The  following  detailed  statement  of  the 
first  I quote  from  the  author’s  treatise  on  the  teeth. 

Case  XVI. — “Mary  B , aged  eighteen,  of  an  unhealthy 

and  somewhat  strumous  aspect,  of  languid  disposition,  and  of 
retiring  and  timid  habits,  came  under  my  care  on  the  3d  of  Janu- 
ary, 1817,  in  consequence  of  severe  and  continued  pain  on  the 
left  side  of  the  face,  of  a dull  heavy  character,  and,  apparently 
deep-seated;  but  occasionally  darting  in  acute  paroxysms,  across 
the  face  towards  the  nose.  The  cheek  was  swollen,  and  the 
palate  somewhat  enlarged.  About  a year  before  the  first  supe- 
rior molaris  of  that  side  had  been  extracted  on  account  of  severe 
pain  in  the  face,  but  without  producing  any  relief,  and  the  pain 
was  consequently  attributed  to  rheumatism,  from  which  com- 
plaint she  had  long  suffered  to  a great  degree,  in  the  shoulder, 
hip,  and  other  joints,  and  for  which  she  had  been  under  the  care 
of  many  medical  practitioners,  both  in  London  and  Bath,  having 
been  sent  to  the  latter  place  for  the  use  of  the  waters.  When  I 

r 

first  saw  her,  the  general  health  was  much  deranged  : the  stomach, 
bowels,  and  liver  performed  their  functions  very  imperfectly  ; and 
the  uterus  partook  of  the  general  sluggishness  of  the  system, 
menstruation  being  almost  wholly  suppressed,  and  the  periods 
only  indicated  by  increased  indisposition,  and  especially  by  an 
exacerbation  of  the  pain  in  the  face. 

No  discharge  had  taken  place  from  the  nose,  but,  from  the 
nature  and  situation  of  the  pain,  the  direction  of  its  paroxysms, 
the  enlargement  of  the  cheek  and  palate,  and  from  an  occasional 
trifling  discharge  of  pus  from  the  alveolus  of  the  tooth  which  had 
been  extracted,  I could  not  doubt  that  the  antrum  was  the  seat  of 

*Mem.  de  l’Acaderaie  Royale  de  Chirurgie,  ed.  12mo.  vol.  xii.  p.  31, 
Obs.  11. 


84 


OF  ABSCESS. 


the  disease.  On  examining  the  teeth,  I found  that  the  second 
bicuspis  also  was  diseased,  and  as  it  had  at  times  occasioned  con- 
siderable pain,  I extracted  it  with  the  view  of  removing  every 
possible  source  of  irritation. 

Six  leeches  were  ordered  to  be  applied  to  the  face,  and  after- 
ward the  continued  application  of  a cold  lotion.  Medicines  were 
also  administered  with  reference  to  the  general  health,  both  as 
regarded  the  digestive  and  uterine  functions ; and  on  January  7, 

I determined  on  puncturing  the  antrum.  I consequently  intro- 
duced the  trocar  through  the  anterior  alveolar  cavity  of  the  first 
molaris,  and  found  that  when  the  instrument  came  in  contact  with 
the  lining  membrane,  the  most  acute  pain  was  produced,  indicat- 
ing the  existence  of  a high  degree  of  inflammation  in  that  struc- 
ture. On  withdrawing  the  trocar,  when  the  antrum  was  freely 
opened,  I was  surprised,  and  a little  disappointed,  at  finding  that 
not  the  smallest  discharge  made  its  appearance.  There  was  a 
small  quantity  of  glairy  mucus,  but  nothing  more.  I introduced 
the  blunt  end  of  a probe,  and  found  that  the  opening  was  quite 
free;  but  on  passing  it  upwards  towards  the  orbit,  its  passage 
was  resisted  by  a firm  elastic  substance,  which  gave  the  impres- 
sion that  a solid  tumour  existed  in  the  upper  part  of  this  cavity, 
and  which  produced  intolerable  pain,  on  being  pressed  with  the 
probe.  I now  injected  some  tepid  water,  and  found  that  the  nasal 
opening  was  pervious,  as  the  water  passed  freely  into  the  nose. 
As  the  operation  had  produced  a considerable  increase  of  pain, 
and  as  the  parts  appeared  a good  deal  inflamed,  1 ordered  six 
leeches  to  be  applied,  the  bowels  to  be  freely  opened,  and  an 
opiate  to  be  taken  at  night. 

January  9. — The  pain  has  been  extremely  severe  ever  since  the 
operation,  with  scarcely  any  mitigation  excepting  for  a few  hours 


OF  ABSCESS. 


85 


after  the  application  of  the  leeches.  A probe  now  introduced  into 
the  antrum,  met  with  similar  resistance,  but  much  nearer  the  ori- 
fice than  before,  proving  that  the  tumour  had  increased;  and  on 
injecting  warm  water,  it  no  longer  passed  into  the  nose.  The 
leeches,  the  aperient,  and  the  opiate  were  repeated. 

January  ] 1. — The  pain  has  continued  without  cessation,  and  no 
sleep  has  been  procured  by  the  opium.  The  inflammation  is  not 
apparently  reduced.  Pulse  one  hundred,  small  and  feeble.  The 
palate  is  a little  enlarged,  but  not  more  so  than  might  be  accounted 
for,  by  the  thickening  of  the  integuments  by  inflammation,  I could 
now  distinctly  feel  with  a probe,  that  the  tumour  was  not  only  in- 
creased in  size,  but  that  it  had  become  softer,  yielding  in  some 
measure  to  pressure,  and  conveying  the  impression  that  it  con- 
tained fluid.  I therefore  introduced  a sharp-pointed  instrument, 
which,  with  a little  force,  pierced  the  tumour,  and  a gush  of  pus 
instantly  took  place,  with  immediate  relief  to  the  symptoms. 

Here,  then,  was  a sac  containing  pus,  existing  doubtless  as  a 
distinct  cyst,  the  result  of  inflammation  in  the  membrane;  for  it  is 
scarcely  probable  that  the  membrane  itself  had  become  separated 
from  its  attachment  by  the  formation  of  pus  between  it  and  the 
bone.  That  the  former  was  the  true  situation  of  the  disease,  may 
be  inferred  from  the  fact  that  no  subsequent  caries  of  the  bone  took 
place,  which  would,  undoubtedly,  have  been  the  case,  had  the 
matter  been  formed  in  contact  with  the  bone  ; and  it  could  scarcely 
have  been  produced  between  the  mucous  membrane  and  the  peri- 
osteum, as  these  two  structures,  though  essentially  distinct  from 
each  other,  are  inseparably  connected. 

The  pus  continued  to  be  discharged  for  a day  or  two,  and  then 
entirely  ceased.  On  passing  the  probe  a week  after  the  former 


S6 


OF  ABSCESS. 


operation,  I found  the  same  resistance  as  before,  and  in  the  same 
situation  ; the  cyst  was  again  punctured,  and  again  the  pus  was 
discharged.  This  alternation  of  the  repletion  and  evacuation  of 
the  cyst  regularly  recurred  for  a considerable  time,  but  the  opening 
into  the  nose  did  not  again  become  stopped.  The  general  health, 
however,  in  the  meanwhile,  improved,  and  the  pain  in  the  face 
was  greatly  diminished,  returning  only,  with  any  degree  of  vio- 
lence, when  the  cyst  was  full. 

At  length  the  repeated  perforation  of  the  sac,  followed  by  the 
use  of  strong  astringent  injections,  and  aided  by  the  remedies  that 
were  directed  to  the  state  of  the  general  health,  restored  the  an- 
trum to  healthy  condition;  the  menstrual  disturbance  was  by  de- 
grees entirely  obviated,  and  the  stomach  at  the  same  time  as- 
sumed its  healthy  function;  but  it  was  two  years  from  the  time 
when  1 first  saw  her  before  she  had  recovered  her  health,  which  at 
the  best  was  never  robust.” 

The  case  described  by  Bordenave,  is,  in  many  respects,  similar 
to  the  foregoing.  The  following  account  of  it  is  taken  from  the 
Memoirs  de  lMcademie  Royale  de  Chirurgie. 

Case  XVII. — “The  subject  of  the  present  case  was  a young 
Russian  of  about  ten  years  of  age.  He  was  seized  with  acute 
pain  in  his  teeth,  which  was  soon  followed  by  tumefaction  of  the 
cheek.  An  abscess  developed  itself  two  days  after,  above  the 
second  molaris,  and  this  was  succeeded  by  a cessation  of  pain. 
For  the  cure  of  this  new  affection,  the  extraction  of  the  decayed 
tooth,  as  also  the  two  neighbouring  ones,  was  decided  on. 
Through  the  alveolus  of  the  first,  the  antrum  was  then  perforated. 
It  was  afterwards  injected  with  appropriate  remedies,  and  the 
opening  prevented  from  closing  by  the  introduction  of  pieces  of 


OF  ABSCESS. 


87 


cotton  into  it.  The  treatment  having  been  conducted  thus  far, 
the  patient  was  put  under  the  care  of  Bordenave.  The  injections 
when  thrown  in  with  force  passed  in  part  through  into  the  nose, 
and  the  liquid  which  returned  brought  with  it  thick  and  fetid 
matter.  From  time  to  time  the  patient  experienced  a sensation  in 
the  sinus  near  the  orbit,  like  what  would  be  produced  by  the 
bursting  of  something,  and  soon  after  each  of  these  paroxysms, 
there  was  a discharge  of  a large  quantity  of  fetid  pus.  When 
the  escape  of  this  matter  was  prevented  by  the  contraction  or 
closing  up  of  the  opening,  a slight  uneasiness  was  experienced. 
To  prevent  this,  Bordenave  dilated  the  opening  with  prepared 
sponge,  and  placed  into  it  a silver  canula  pierced  with  several 
holes,  for  the  purpose  of  permitting  the  matter  freely  to  escape. 
Time  after  time  the  matter  became  thick  and  lumpy,  and  on  an 
occasion  when  the  canula  was  withdrawn  to  be  cleaned,  the 
patient,  by  sucking,  effected  a discharge  of  foreign  matter.  At 
the  expiration  of  six  months,  the  matter  having  become  of  a better 
quality,  the  use  of  the  canula  was  discontinued.  Its  replacement 
however,  as  Bordenave  supposed,  having  again  soon  become  ne- 
cessary, it  was  restored,  and  its  use  continued  for  nearly  two 
years,  at  the  expiration  of  which  time  the  quality  of  the  matter 
had  become  healthy.  The  patient  ceased  to  feel  any  uneasiness 
in  the  sinus,  but  as  the  opening  did  not  close,  it  was  slightly 
cauterized.  It  now  soon  healed,  and  at  the  end  of  1758,  the  dis- 
ease had  terminated.  For  the  correctness  of  the  foregoing  state- 
ment, Bordenave  refers  to  M.  Morand,  who  visited  the  patient 
with  him.” 

It  is  highly  probable  that,  had  this  case  been  treated  in  the 
manner  in  which  Mr.  Bell  treated  his,  a cure  would  have  been 


88 


OF  ABSCESS. 


much  sooner  effected.  I should  think  it  highly  important  that  the 
matter  should  have  free  egress  both  from  the  cyst  in  which  it  is 
secreted,  and  from  the  antrum  as  soon  as  it  escapes  from 
that  into  it. 

Finally,  that  abscess  does  occasionally  form  in  other  parts  of 
this  cavity  than  the  base,  is  conclusively  proven  by  the  two  last 
cases.  It  is  true,  these  are  the  only  ones  of  which  we  have  any 
account,  yet,  nevertheless,  they  establish  the  fact  that  it  is  possible 
for  them  to  occur  in  any  part  of  the  sinus. 


CHAPTER  Y. 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 

This  is  not  an  idiopathic  affection.  It  is  always,  I believe, 
symptomatic  of  some  other  morbid  condition  of  the  mucous  mem- 
brane of  this  cavity,  and  often  gives  rise  to  some  of  the  worst  and 
most  aggravated  forms  of  disease  that  are  ever  here  met  with.  It 
is  not  therefore  a simple  disease,  but  is  complicated  with  the  one 
that  caused  it,  and  often  with  some  other  to  which  it  has  given  rise. 
I shall  treat  of  it,  however,  as  a separate  affection.  Its  attacks  are 
preceded  by  a purulent  condition  of  the  fluids  of  the  antrum,  and 
are  often  followed  by  fungi  and  sometimes  by  caries  of  the  sur- 
rounding osseous  walls.  The  membrane  covering  the  floor  of 
the  cavity,  is  usually  first  attacked,  but  ulcers  having  formed  here, 
they  generally  soon  extend  themselves  to  other  parts  of  the  sinus. 

Ulceration  of  the  lining  membrane  of  the  maxillary  sinus  is  fre- 
quently complicated  with  ulceration  of  the  lining  membrane  of 
one  or  both  of  the  nasal  cavities ; and,  it  is  sometimes  mistaken 
for  ulceration  in  the  nose,  but  it  is  not  easy  thus  to  mistake  the 
seat  of  the  disease.  The  existence  of  ulcers  in  the  antrum  can 
only  be  inferred  from  certain  signs,  but  when  seated  in  the  nose, 
they  can  almost  always  be  seen,  and  besides,  the  matter  secreted 
by  those  situated  here,  exhales  a less  fetid  odor  than  does 
that  of  ulcers  of  the  maxillare  sinus.  The  reason  of  this  is 
obvious.  The  air  that  finds  its  way  into  this  cavity  is  retained  in 
11 


90 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


it  a long  time  and  consequently  becomes  more  highly  impregnated 
with  the  fetor  of  the  matter  secreted  in  ulcers  situated  here,  than 
it  does  with  that  of  ulcers  of  the  nose,  over  which,  it  is  almost 
constantly  passing.  This  of  itself,  as  has  been  justly  remarked  by 
Deschamps,*  will  enable  us  to  determine,  almost  to  a certainty, 
the  seat  of  the  disease.  But  there  are  other  signs  that  will  assist 
us  in  ascertaining  its  location.  The  foregoing,  however,  are 
sufficient,  especially  when  taken  in  connection  with  the  symp- 
toms that  precede  the  formation  of  the  ulcers. 

Ulcers  of  the  maxillary  sinus  present  as  great  a variety  of  cha- 
racter as  do  those  of  other  parts  of  the  body.  Their  nature  is 
determined  by  the  state  of  the  constitutional  health  and  the  causes 
that  produce  them.  But  it  is  not  necessary  to  go  into  a minute 
description  of  the  various  kinds  of  ulcers  that  are  here  met  with. 
It  will  suffice  to  state  that  they  for  the  most  part  partake  of  the 
disposition  of  the  subject  in  which  they  occur,  and  that  the  follow- 
ing varieties  have  been  met  with ; namely,  the  simple,  or  that 
resulting  from  mechanical  injury ; the  fungus,  the  scorbutic, 
venereal,  cancerous,  gangrenous,  scrofulous,  inveterate,  carious, 
&c.  &c.  Sir  Everard  Home  divides  ulcers  into  six  kinds,  each 
of  which  being  determined  by  the  nature  or  condition  of  the  part 
that  it  is  situated  in.f  The  first,  are  ulcers  in  parts  endowed 
with  sufficient  strength  or  curative  power  to  effect  their  restora- 
tion. The  second,  are  those  situated  in  parts  too  weak  to  effect  a 
recovery.  The  third,  are  ulcers  in  parts  having  too  great  an 
action  for  the  formation  of  healthy  granulations.  The  fourth,  are 
those  seated  in  parts  possessed  of  too  indolent  an  action,  whether 

# Maladies  des  Fosses  Nazales,  sec.  2,  Art.  vi.  p.  262. 

t Cooper’s  Surgical  Dictionary,  vol.  ii.  p.  381. 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


91 


arising  from  the  state  of  the  parts  or  general  constitutional  health. 
The  fifth,  are  ulcers  located  in  parts  that  have  acquired  some 
specific  diseased  action.  The  sixth  and  last,  are  those  situated  in 
parts  that  are  prevented  from  giving  out  healthy  granulations,  by 
a “varicose  state  of  the  superficial  veins  of  the  upper  part  of  the 
limb.”  But,  these  remarks  are  applicable  only  to  ulcers  in  gene- 
ral ; yet,  as  those  of  the  maxillary  sinus  often  present  characte- 
ristics similar  to  those  of  other  parts  of  the  body,  they  may  not  be 
deemed  inappropriate  here.  The  kind  of  ulcer  last  noticed,  how- 
ever, never  occurs  in  the  antrum. 

In  the  simpler  species  of  ulcer,  the  matter  is  of  a thick  consis- 
tence and  nearly  white,  but  as  the  disease  increases  in  malig- 
nancy, it  is  thinner  and  varies  in  appearance  from  transparent  to 
a dirty  brown,  yellow  or  black. 

Symptoms. — Many  of  the  signs  attendant  upon  ulceration  of  the 
mucous  membrane  of  the  maxillary  sinus,  are  similar  to  some  that 
accompany  other  affections  of  this  cavity,  as  for  example,  deep- 
seated  heavy  pain  in  the  cheek,  the  occasional  escape  of  matter 
into  the  nose,  &c.  &c.  But  in  addition  to  constant  pain  in  the 
region  of  the  antrum,  the  following  may  be  mentioned  as  signs 
indicative  of  ulcers  of  this  cavity.  The  escape  of  a fetid  sanies 
into  the  nose  on  the  patient’s  inclining  his  head  to  the  opposite 
side,  or  through  an  opening  which  it  has  itself  effected,  or  that  has 
been  formed  by  art  for  its  escape.  Also,  the  traversing  of  the 
ulcer  from  the  interior  through  the  bony  walls  of  the  cavity  and 
external  soft  parts.  An  opening  of  this  sort  may  be  effected 
through  the  cheek,  near,  or  even  into  the  orbit,  which  last  has 
often  happened;  at  other  times  it  is  effected  through  the  canine 
fossae  or  palatine  arch.  Moreover,  the  matter  escaping  from  the 


92  OF  ULCERATION  OF  THE  LINING  MEMBRANE. 

sinus,  often  has  floculi  mixed  with  it,  which  is  never  the  case,  in 
simple  muco-purulent  secretion  of  the  sinus.  These  floculi  some- 
times, as  has  been  before  stated,  choke  up  the  natural  opening  of 
the  cavity  and  cause  its  secretions,  together  with  those  of  the 
ulcers  to  accumulate,  and  distend  its  osseous  walls  until  they 
ultimately  give  way,  or  an  opening  is  formed  for  their  escape.  It 
occasionally  happens  however,  that  the  floculi  that  have  gotten 
into  the  nasal  opening,  and  thus  prevented  the  egress  of  the  fluids 
secreted  here,  after  choking  up  this  conduit  for  a long  while, 
suddenly  give  way  and  permit  the  matter  to  pass  out  into  the 
nose. 

When  the  ulcer  is  of  a fungous  character,  the  matter  secreted 
by  it,  is  thin  and  of  a dark  brown  or  blackish  colour;  and  it  has 
mixed  with  it  blood  and  pus.*  It  is  also,  says  Deschamps,  slightly 
painful,  and  can  only  be  distinguished  from  other  ulcers  by  the 
introduction  of  the  bougie  into  the  sinus,  and  that  like  polypus,  it 
is  capable  of  spreading  itself  and  penetrating  every  opening  that 
will  give  it  passage;  but  in  consequence  of  its  being  of  a softer 
consistence,  it  makes  less  impression  upon  the  surrounding  parts. 

If  the  ulcer  be  of  a cancerous  nature,  the  pain  will  be  sharp 
and  lancinating  and  affect  the  whole  of  the  side  of  the  face;  the 
matter  will  be  serous,  very  fetid,  and  streaked  with  blood.  If  it  is 
discharged  through  the  natural  opening  into  the  nose,  it  will  cause 
the  pituitary  membrane  of  the  nasal  cavity  of  the  affected  side  to 
become  exceedingly  irritable,  sensitive  to  the  touch,  and  ulcerated. 
The  bones  of  the  affected  side  of  the  face  soon  become  softened  or 
carious,  the  teeth  loosen,  and  the  external  soft  parts  inflame  and 
ultimately  ulcerate  ; openings  are  formed  into  the  sinus,  fever  of 
a low  grade  supervenes,  and  ultimately  death  closes  the  scene. 

* Maladies  des  Fosses  Nazales,  sec.  2,  Art.  vi.  p.  263. 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


93 


Causes. — A degenerated  or  altered  state  of  the  secretions  of 
this  cavity,  is  said  to  be  the  most  common  cause  of  ulcers  in 
it.*  This  may  be  an  exciting  cause,  and  it  may  be  one  of 
the  most  frequent  exciting  causes,  but  were  it  not  favoured  by  a 
constitutional  predisposition  or  tendency,  it  would  not  perhaps 
often  give  rise  to  them.  Local  irritation,  whether  produced  by 
an  altered  condition  of  the  fluids  of  this  cavity  or  by  the  presence 
of  decayed  or  dead  teeth,  the  roots  of  teeth,  or  a blow  upon  the 
cheek,  may  be,  and  doubtless  is,  the  exciting  cause  of  ulcers  in 
the  mucous  membrane  of  the  maxillary  sinus.  This,  however,  in 
a subject  of  good  constitutional  health,  would  have  to  be  very 
severe  and  continue  for  a long  time,  to  result  in  ulceration  of  this 
membrane,  and  even  then,  a cure  would  soon  be  effected  by  the 
restorative  efforts  of  the  economy.  It  is  only  in  bad  habits, 
or  debilitated  constitutions,  that  malignant  ulcers  are  often  met 
with  in  the  maxillary  sinus. 

Deschamps,  although  he  acknowledges  that  diseased  teeth  often 
exercise  a morbid  influence  upon  this  cavity,  and  that  the  apices 
of  the  roots  of  these  organs  are  sometimes  in  contact  with  its 
mucous  or  lining  membrane,  seems  nevertheless  to  doubt  that  they 
have  any  agency  in  the  production  of  ulcers  here.  His  reasoning 
upon  the  subject,  however,  is  far  from  satisfactory.  While  he 
admits  that  by  the  contact  and  adhesion  of  the  dental  periosteum  and 
mucous  membrane  of  this  cavity,  by  the  penetration  of  its  floor 
by  the  roots  of  teeth,  inflammation  and  ulceration  may  be  pro- 
duced, he  denies  that  this  can  be  positively  proven.  Now, 
although  we  may  not  be  able  to  adduce  positive  evidence  in  con- 
firmation of  it,  the  circumstantial  proofs  which  we  have,  are  so 
* Maladies  des  Fosses  Nazales,  sec.  2,  Art.  vi.  p.  159. 


94 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


clear  and  strong,  that  no  candid  inquirer  can  for  a single  moment 
doubt  that  the  disease  in  question,  when  favoured  by  a bad  habit 
of  body,  often  results  from  dental  or  alveolar  irritation.  And,  in 
reply  to  the  question  which  he  a little  further  on  propounds,  “How 
can  the  extraction  of  a tooth  be  of  service  in  the  subduction  of 
inflammation  of  the  mucous  membrane  with  which  the  dental 
periosteum  is  only  simply  in  contact,”*  I answer  that  by  this  ope- 
ration a constant  source  of  irritation  may  be,  and  often  is  removed. 
But,  ulcers  having  absolutely  formed  here,  a cure  cannot  always 
be  effected  by  the  removal  simply  of  the  exciting  cause. 

But,  inflammation  of  the  lining  membrane  of  the  maxillary 
sinus,  and  as  a consequence,  an  altered  condition  of  its  secretions, 
may,  it  cannot  be  denied,  be  produced  by  other  causes  than  irri- 
tation resulting  from  a diseased  condition  of  the  teeth,  and  it  is  to 
this,  that  ulceration  in  it,  is  attributable. 

Treatment. — As  in  the  case  of  mucous  engorgement  of  this  cavity, 
the  first  indication  of  cure  is  to  give  egress  to  the  purulent  matter, 
and  in  this  as  in  the  other  affection,  the  opening  should  be  formed 
at  the  most  dependent  part  of  the  sinus  ; and  this  should  be  effect- 
ed in  the  manner  as  before  described  through  the  alveolar  border 
or  rather  alveolus  of  a molaris.  It  should  be  made  large  enough 
to  admit  the  little  finger,  and  if  there  be  any  teeth  so  much  affect- 
ed as  to  be  productive  of  irritation  to  the  parts  subjacent  to  the 
antrum,  they  should  at  the  same  time  be  removed. 

Free  egress  for  the  matter  having  been  obtained,  and  all  local 
irritants  removed,  the  antrum  should  be  injected  from  time  to  time, 
with  gently  stimulating  and  detersive  fluids.  This,  in  cases  of 
simple  ulcer,  if  the  constitutional  health  be  not  seriously  impaired, 
* Maladies  des  Fosses  Nazales,  sec.  2.  Art.  vi.  p.  259. 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


95 


will  often,  as  is  proven  by  the  result  of  the  treatment  detailed  in 
the  history  of  the  following  case,  be  all  that  is  necessary  to  effect 
a cure. 

Case  XYIII. — Mrs.  R , ret.  about  twenty-five  years,  of  a 

scrofulous  habit,  having  been  affected  for  several  months  with  a pain 
in  her  left  cheek,  which  at  times  was  very  severe,  and  supposing  it 
might  be  connected  with  her  teeth,  applied  to  me  in  the  winter  of 
1836,  for  the  purpose,  if  possible,  of  obtaining  relief.  She  informed 
me  that  she  had  been  several  times  temporarily  relieved  by  a sud- 
den discharge  of  matter  from  the  nostril  of  the  affected  side,  after 
sneezing,  and  once  after  a violent  expiration  through  this  cavity  of 
the  nose  while  the  other  was  closed.  I at  once  suspected  the 
disease  to  be  ulceration  of  the  mucous  membrane  of  the  antrum, 
and  a purulent  condition  of  its  secretions. 

On  examining  her  mouth,  I found  the  most  of  her  teeth  to  be 
more  or  less  affected  with  caries.  The  crowns  of  the  first  and 
second  superior  molares  of  the  left  side  were  nearly  destroyed, 
and  over  the  roots  of  the  second,  externally,  was  a fistula  from 
which,  matter  had  at  times  been  discharged,  as  I was  informed, 
for  several  years.  This  communicated  with  an  abscess  partly 
between  the  apices  of  its  three  roots  ; and,  as  neither  this  nor  the 
first  molaris  was  of  any  service,  their  restoration  being  wholly 
impracticable,  and  as  both  obviously  exercised  a morbid  in- 
fluence upon  the  neighbouring  parts,  I advised  their  immediate 
removal.  To  this  operation,  she  readily  submitted,  and  it  hav- 
ing been  performed,  I at  once  perforated  the  antrum  through  the 
socket  of  the  second  tooth,  by  means  of  a suitable  trocar.  The 
withdrawal  of  the  instrument  was  followed  by  the  discharge  of 
more  than  a table-spoonful  of  thickened  fetid  mucus,  streaked 


96 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


with  blood  and  pus.  The  opening  was  enlarged  to  about  the  size 
of  a goosequill  and  the  sinus  injected  with  tepid  water  and  the 
tincture  of  myrrh.  The  opening  was  prevented  from  closing  by 
means  of  a bougie  prepared  for  the  purpose.  Whenever  this  was 
removed  during  the  first  eight  or  ten  days,  a small  quantity  of 
whitish  pus  was  discharged  with  the  mucus  that  came  away. 
The  injections  were  continued  for  about  four  weeks,  and  at  the 
expiration  of  this  time,  as  the  secretions  of  the  antrum  had  ceased 
to  be  offensive,  and  as  they  were  no  longer  mixed  with  pus,  the 
bougie  was  left  out  and  the  opening  permitted  to  close.  A com- 
plete cure  was  effected. 

If  the  ulcer  be  of  a fungous  nature,the  employment  of  escharotics, 
and  sometimes  even  the  actual  cautery  becomes  necessary,  and 
this  last  should  be  repeated  until  the  fungi  are  completely  destroyed. 
With  regard  however  to  the  employment  of  escharotics,  such  as 
the  nitrate  of  silver,  blue  vitriol,  &c.  &c.  for  the  purpose  of  destroy- 
ing luxuriant  granulations  in  ulcers,  Sir  E.  Home*  is  of  the  opin- 
ion that  it  is  better  to  combine  them  with  some  other  substance,  so 
as  to  prevent  them  from  immediately  destroying  the  granulations. 
He  believes  that  when  this  is  done,  the  surface  of  the  ulcer  under- 
neath, is  more  liable  to  reproduce  them,  than  when  they  are 
removed  by  absorption,  and  it  is  for  this  reason  that  he  prefers,  in 
the  employment  of  caustics,  to  mix  them  with  other  substances, 
so  that  they  shall  only  exercise  a strongly  stimulating  effect,  and 
thus  cause  the  granulations  to  be  gradually  removed  by  the  action 
of  the  absorbents. 

The  surface  of  the  ulcer  should,  if  practicable,  be  kept  clean  by 
means  of  dosils  of  dry  lint  or  pledgits  spread  with  some  simple 

* Cooper’s  Surgical  Dictionary,  vol.  ii.  p.  382. 


OF  ULCERATION  OF  THE  LINING  MEMBRANE.  97 

ointment.  The  treatment  of  ulcers  of  this  cavity,  however,  is 
usually  attended  with  more  difficulty,  on  account  of  their  con- 
cealed situation,  than  those  of  most  of  the  other  parts  of  the  body. 
Among  other  things,  Deschamps  recommends  injections  of  a de- 
coction of  quinine.  In  many  cases  a lotion  of  sulphate  of  zinc 
may  be  used  with  advantage.  But  the  remedies  to  be  em- 
ployed in  the  treatment  of  ulcers  of  the  maxillary  sinus,  as  in  the 
treatment  of  ulcers  of  other  parts,  should  be  varied  to  suit  the 
indications  of  each  particular  case.  In  debilitated  subjects,  tonics, 
such  as  quinine  and  preparations  of  steel  are  said  to  be  highly 
serviceable.  There  are  some  cases  in  which  mercurials  are 
highly  beneficial.  Strict  attention  should  always  be  paid  to  the 
regimen  of  the  patient,  and  such  general  treatment  adopted  as 
may  be  best  calculated  to  restore  the  constitutional  health,  for 
upon  this,  the  cure  of  the  local  affection  often  depends. 

If  the  ulcer  be  of  an  irritable  nature,  warm  fomentations,  con- 
veyed to  the  interior  of  the  antrum  by  means  of  a properly  con- 
structed funnel,  of  a decoction  of  poppy  heads,  chamomile 
flowers,  or  the  leaves  of  hemlock,  will  often  prove  beneficial  in 
soothing  the  pain.  Tincture  of  myrrh,  diluted,  or  a decoction  of 
walnut  leaves  may  often  be  advantageously  employed  as  injections 
in  cases  of  indolent  ulcers, — the  last  of  which,  is  recommended  as 
an  application  to  ulcers  of  this  character  in  other  parts  of  the 
body  by  Hunezawsky,*  and  both  of  which  are  favourably  spoken 
of  by  Sir  E.  Home.f  This  last  named  writer  recommends  “diluted 
sulphuric  acid  and  the  juice  of  the  powder  of  different  species  of 
pepper  in  a recent  state,”  and  also  nitrous  acid  diluted  with 

* Acta  Acad.  Med.  Chirurg.  Vindob.  t.  1.  1788. 

I Cooper’s  Surgical  Dictionary,  vol.  ii.  p.  3 85. 

12 


98 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


water.  The  unguentuin  hydrargyri  nitrate,  mixed  with  lard,  and 
the  ceratum  resinee,  and  the  unguentum  elemi,  mixed  with  the 
balsam  of  turpentine,  are  also  recommended,  but  the  application 
of  ointments  to  ulcers  of  this  cavity  is  always  attended  with  in- 
convenience, and  it  is  on  this  account  that  they  are  less  easily 
cured  when  seated  here  than  when  situated  in  other  parts  of  the 
body. 

Many  of  the  ulcers  of  the  maxillary  sinus  are  regarded  as 
incurable,  as  for  example,  such  as  are  of  a cancerous  nature,  and 
ulcerated  fungus  haematodes.  But  although  the  resources  of 
surgery  have  hitherto,  in  most  instances,  proved  inadequate  to  the 
cure  of  these  formidable  diseases,  yet  nevertheless  they  should  be 
put  in  requisition,  and  we  should  endeavour  to  combat  them  by 
every  means  in  our  power.  Deschamps  says,  the  interior  of  the 
antrum  should  be  exposed  at  the  commencement  of  the  disease. 
He  recommends  the  formation  of  a large  opening,  if  the  alveolar 
ridge  be  healthy,  above  it,  if  not,  through  it.*  As  much  of  the 
cavity  as  possible  should  be  exposed.  This  done,  he  directs,  if 
there  be  a cancerous  tumour,  that  it  be  as  thoroughly  extirpated 
by  means  of  a curved  and  flat  bistory  or  curved  scissors  as  possi- 
ble. All  that  may  have  escaped  removal  by  this  means  he  says, 
should  be  touched  with  the  actual  cautery.  These,  he  says,  are 
the  only  remedies  “to  be  employed  when  the  membrane  is  in  a 
state  of  cancerous  ulceration.”  The  surgeon,  he  adds,  “should 
destroy  the  parts  in  such  a way  as  to  leave  only  the  osseous  sur- 
faces, and  he  should  pay  some  attention  to  these  bony  parts, 
which  also  he  should  carefully  cauterize. ”f  The  disease  having 

'*  Maladies  des  Fosses  Nazales,  sec,  ii.  Art.  vi.  p.  265. 

| Maladies  des  Fosses  Nazales,  Sec.  2.  Art.  vi.  p.  266. 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


99 


been  thus  removed,  the  surrounding  osseous  walls  that  have  been 
cauterized  will  soon  exfoliate,  when  a chance  for  a cure  will  be 
afforded,  and  of  which,  if  the  neighbouring  parts  have  not  been 
so  extensively  invaded,  nature  will  avail  herself.  The  administra- 
tion of  soothing  and  anodyne  medicines  are  also  directed.  Ar- 
senic has  been  employed  with  advantage  both  as  an  external  and 
as  an  internal  remedy  in  ulcers  of  this  kind. 

There  are  other  kinds  of  ulcers  of  this  cavity,  but  it  is  not 
necessary  here  to  describe  the  treatment  for  each  of  the  various 
forms  which  this  description  of  disease  puts  on.  Particular  and 
ample  directions  for  that  of  each  are  laid  down  by  writers  on 
affections  of  this  kind,  and  though  they  may  not  have  special 
reference  to  their  occurrence  in  the  antrum  maxillare,  they  will, 
for  the  most  part,  be  found  as  applicable  to  them  here,  as  when 
they  are  seated  in  other  parts  of  the  body. 

The  following  case  of  fungus  ulcer  complicated  with  alteration 
of  the  walls  of  the  sinus  is  taken  from  Bordenave’s  collection  of 
observations  on  the  diseases  of  this  cavity,  in  the  Memoirs  of  the 
Royal  Academy  of  Surgery.*  Although  the  history  of  the  case, 
in  its  translation,  is  abridged  a little,  yet  no  important  fact  con- 
nected with  it  is  here  omitted. 

Case  XIX. — The  subject  of  this  case  was  a women  twenty- 
six  years  of  age,  and  who  having  exposed  herself,  while  in  a criti- 
cal state  of  health,  to  cold  air,  was  in  1759,  attacked  with  acute 
pains  in  the  left  side  of  her  upper  jaw,  in  the  alveolar  ridge  of 
which,  were  the  roots  of  several  decayed  teeth.  The  following 
day  her  jaw  was  much  swollen,  and  although  the  pain  ceased  in 
a few  days,  the  swelling  still  continued,  without  any  change  in  the 

* Ohs.  xvii.  in  tom.  12th,  12mo.  ed.  p.  56. 


100 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


appearance  of  the  skin  ; yet  nevertheless,  her  face  was  deformed 
in  shape.  The  orbitarv  apophosis  of  the  maxillary  bone  became 
elevated,  and  the  substance  of  the  bone  softened.  The  interior  of 
the  nose  was  also  affected  and  the  opening  of  the  sinus  into  this 
cavity  was  closed.  The  matter  collected  in  the  antrum  began  to 
escape,  twenty-two  days  after  the  attack,  through  the  alveoli. 

In  January,  1761,  the  symptoms  becoming  more  aggravated, 
she  went  to  Paris  in  search  of  medical  aid.  M.  Beaupreau  was 
consulted,  and  on  examining  the  affected  parts,  determined  on  the 
extraction  of  the  decayed  teeth,  which  were  considerably  broken. 
They  however  adhered  so  firmly  to  their  alveolar  cavities  that  he 
could  not  move  them  without  shaking  their  sockets.  This  deter- 
red him  from  proceeding  with  the  operation  as  he  had  begun, 
and  he  resolved  to  remove  the  whole  of  the  alveolar  border  with 
a bistory,  from  the  lateral  incisor  to  the  first  molaris,  and  in  this 
way  remove  the  teeth  with  the  bone.  This  done,  he  made  a sec- 
tion of  the  bone,  which  had  become  softened,  with  a pair  of 
scissors,  in  the  direction  of  the  cuspidatus.  The  antrum  was 
much  dilated;  its  membrane  fungous  and  ulcerated.  He  then 
treated  it  with  detersive  injections,  adhesive  dossils,  covered  with 
digestives,  composed  of  the  oil  of  turpentine.  In  addition  to  these, 
mercurial  ointment  and  red  precipitate  were  used.  Alterative 
pills  and  beverages  clarified  with  cress,  were  also  prescribed; 
and  this  treatment  was  successful, for,  five  days  after  it  had  been 
commenced,  the  tumour  had  perceptibly  diminished,  the  pus  be- 
came of  a better  quality  and  less  in  quantity.  At  the  expiration 
of  two  months  the  discharge  became  mucous.  Injections  of  lime 
water,  at  first  strong,  and  afterwards  milder,  were  used.  The 
natural  opening  was  closed,  and  it  continuing  impervious,  an  open- 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


101 


ing  through  t he  base  of  the  sinus  was  preserved.  At  the  expira- 
tion of  two  months  the  parts  had  recovered,  and  the  general 
health  of  the  patient  was  restored. 

The  medical  treatment,  in  the  foregoing  case  was  very  proper; 
it  accorded  with  the  curative  indications  of  the  disease,  but  the 
surgical,  evidently  involved  a greater  sacrifice  of  parts  than  was 
absolutely  called  for.  The  extraction  of  teeth  was  not,  however, 
as  well  understood  at  that  time  as  at  present,  and  it  was  to  the 
want  of  proper  knowledge  and  skill  in  this  department  of  surgery, 
that  the  removal  of  so  considerable  a portion  of  the  alveolar  ridge 
was  had  recourse  to.  It  is  often  necessary,  it  is  true,  to  make  a 
very  large  opening  into  the  sinus,  but  it  is  seldom  requisite  to 
make  one  as  large  as  the  one  that  must  have  been  made  in  this 
instance;  and  although  nearly  the  same  treatment  was  adopted 
in  a case  of  a somewhat  similar  nature  by  Bourdet,*  the  practice 
is  nevertheless  objectionable.  When  the  subjacent  bone  and 
alveolar  border  are  in  a carious  or  necrosed  state,  their  removal 
would  be  proper,  and  there  are  diseases  that  occur  in  this  cavity 
which  render  the  operation  necessary,  but  in  neither  of  the  cases 
just  noticed  were  the  bones  carious,  nor  was  the  nature  of  the  dis- 
eases such  as  to  require  so  large  an  opening.  In  the  first  case, 
the  outer  wall  of  the  sinus,  as  would  seem  from  the  description 
given,  was  softened,  but  in  the  other,  Bourdet  says  the  bones  were 
not  diseased. 

It  sometimes  happens  that  when  the  inferior  opening  is  very 
large,  it  never  closes,  and  when  the  natural  opening  becomes 
obliterated,  it  is  requisite  to  preserve  one  through  the  alveolar 
ridge;  in  either  of  these  cases  the  employment  of  an  obturator  is 

* Dissertation  sur  les  Depots  du  Sinus  Maxillare,  obs.  Ill,  p.  13. 


102 


OF  ULCERATION  OF  THE  LINING  MEMBRANE. 


necessary  to  prevent  particles  of  food  and  extraneous  matter  from 
getting  into  the  sinus.  But  of  these,  I shall  hereafter  speak. 

The  history  of  many  more  highly  interesting  cases  of  ulceration 
of  the  mucous  membrane  of  this  cavity,  might  be  here  introduced, 
but  as  this  form  of  diseased  action  is  so  often  complicated  with 
caries,  necrosis  and  other  alterations  of  its  osseous  walls,  I have 
thought  that  it  would  be  as  well  to  reserve  them  until  I came  to 
treat  of  those  affections;  which  I shall  now  proceed  to  do. 


CHAPTER  YI. 


OF  CARIES,  NECROSIS  AND  SOFTENING  OF  ITS  BONY 

PARIETES. 

Various  opinions  concerning  the  pathological  peculiarities  of 
the  several  morbid  conditions  of  the  osseous  tissues  of  the  body- 
have  been  advanced ; but  it  is  not  my  intention,  at  this  time,  to 
notice  any  of  them,  further  than  may  be  necessary  to  a correct 
explanation  of  the  curative  indications  of  the  diseases  of  those  of 
the  maxillary  sinus. 

The  bones,  endowed  with  vitality,  are,  like  other  parts  of  our 
organization,  liable  to  disease.  They  are  furnished  with  blood- 
vessels, nerves  and  absorbents,  from  which  they  derive  nourish- 
ment, and,  the  teeth  excepted,  the  power  of  undergoing  various 
changes.  These  attributes  however  are  more  peculiar  to  some 
bones  than  others.  The  power  of  recuperation,  for  example,  is 
possessed  in  a much  higher  degree  by  cylindrical  than  by  flat 
bones,  and  the  teeth  are  entirely  destitute  of  this  attribute.  Unlike 
other  bones,  they  are  incapable  of  repairing  any  loss  of  substance 
which  they  may  sustain  from  mechanical  violence  or  other  causes. 
Nor  do  their  morbid  conditions,  exostosis  and  necrosis  excepted, 
bear  any  resemblance  to  those  of  other  bones. 

Excepting  then,  the  affections  of  these  organs,  the  diseases  of 
the  bones  are  regarded  by  most  writers,  as  analogous  to  those  of 


104  OF  CARIES,  NECROSIS  AND  SOFTENING 

the  soft  parts,  and  like  which,  they  too,  are  said  to  be  susceptible 
of  being  affected  by  constitutional  vices. 

By  the  ancients,  caries  and  necrosis  were  regarded  as  one  and 
the  same  disease.  Modern  surgeons,  however,  discriminate  one 
from  the  other.  Caries  of  bones,  is  represented  as  analogous  to 
ulceration  of  soft  parts,  while  necrosis  is  said  to  be  similar  to  mor- 
tification. Caries  does  not  at  once  destroy  the  vitality  of  the  bone  ; 
a diseased  action,  tending  to  soften  and  otherwise  alter  the  texture 
of  it,  is  often,  for  a long  time  carried  on  ; its  cells  are  filled  with 
fungous  flesh,  while  there  is  constantly  discharged  from  the  affect- 
ed part,  a dark-coloured  fetid  sanies.  Necrosed  bone,  is  deprived 
of  all  vitality.  The  whole  or  only  a part  of  a bone,  (except  when 
it  occurs  in  a tooth,  and  then  the  whole  organ  perishes,)  may  be 
affected  by  it. 

Besides  caries  and  necrosis,  there  are  other  morbid  conditions 
to  which  bones  are  liable,  but  I shall  not,  at  this  time,  speak  of 
but  one,  and  that  consists  in  a softening  of  their  texture,  which, 
by  surgeons,  is  designated  by  the  name  of  mollifies  ossium.  This 
softening  is  supposed  by  some,  to  be  owing  to  the  absorption  of 
the  phosphate  of  lime  of  these  tissues,  but  I am  inclined  to  the 
opinion  that  it  is  occasioned  by  the  chemical  decomposition  of 
this  earthy  material,  by  some  morbid  or  altered  fluid  exhaled  or 
poured  out  upon  the  bone  or  part  of  the  bone  thus  affected. 

Having  premised  these  few  general  remarks,  I shall  proceed  to 
notice  more  particularly  the  affections  to  which  I have  just 
adverted  as  occurring  in  the  walls  of  the  maxillary  sinus.  The 
bony  parietes  of  this  cavity,  and  sometimes  the  whole  of  the  sub- 
jacent alveolar  border  and  even  that  of  the  superior  maxillary, 
and  the  nasal,  palatine  and  orbital  bones,  as  well  as  some  that 


OF  ITS  BONY  PARIETES. 


105 


belong;  to  the  base  of  the  cranium  and  the  malar  bone,  are  involved 
in  caries  or  necrosis.  Mollities  ossium,  though  it  rarely  occurs  in 
the  alveolar  ridge,  frequently  affects  the  walls  of  the  sinus.  Caries 
may  affect  a considerable  portion  of  both  for  a long  time,  without 
completely  destroying  the  vitality  of  the  diseased  parts,  and  dur- 
ing its  continuance  a fetid  sanies  will  be  discharged  from  one  or 
more  fistulous  openings  through  some  part  of  the  cheek,  alveoli, 
gums,  palatine  arch,  or  into  the  sinus,  and  from  thence  through 
the  natural  opening  into  the  nose.  The  disease  however  eventually 
terminates  in  the  decomposition  and  death  of  the  parts  affected  by 
it,  and  then  by  an  operation  of  the  economy,  this  is  separated  from 
the  living  bone  and  thrown  off,  or  in  other  words,  is  exfoliated. 
But,  although  caries  ultimately  causes  the  death  of  the  bone  or 
part  of  the  bone  affected  by  it,  it  does  not  always  precede  the  des- 
truction of  vitality  in  osseous  tissues.  The  occurrence  of  necrosis 
therefore,  although  it  may  result  as  a consequence  of  caries,  is  not 
necessarily  dependent  upon  it. 

When  the  parietes  of  the  antrum  or  alveoli  are  affected  by 
necrosis,  the  soft  parts  in  contact  with  the  diseased  or  dead  bone, 
inflame,  ulcerate  and  discharge  a fetid  ichorous  matter.  The 
gums  sometimes  become  gangrenous  and  slough.  The  destruc- 
tion of  the  vitality  of  the  osseous  parts  often  progresses  very  slowly, 
and  thus  piece  after  piece  is  exfoliated  until  the  disease  is  arrested. 

But  besides  these  affections,  it  not  unfrequently  happens  that  the 
osseous  parietes  of  the  antrum,  are  so  softened  as  to  be  easily 
bent.  This  alteration  of  the  bone,  as  well  as  the  others  just 
noticed,  are,  in  nearly  every  instance  preceded  by  some  other 
affections  of  this  cavity. 

The  annoyance  occasioned  by  caries  and  necrosis  of  the  bony 

13 


106 


OF  CARIES,  NECROSIS  AND  SOFTENING 


walls  of  this  cavity  or  of  the  alveoli,  to  the  unhappy  patient,  is 
very  great.  The  fetor  of  the  sanies  is  sometimes  almost  insuffer- 
able, and  moreover,  this  matter  often  excoriates  and  inflames  the 
parts  with  which  it  comes  in  contact  to  such  a degree,  as  to  cause 
them  to  become  exceedingly  sensitive  and  not  unfrequently  to 
ulcerate. 

Symptoms. — It  is  sometimes  difficult  to  distinguish  caries  and 
necrosis  of  the  bony  parietes  of  the  antrum  from  some  of  the 
affections  that  seat  themselves  within  this  cavity.  They  therefore 
often  exist  for  a long  time  without  being  suspected.  But,  the  signs 
that  indicate  mollities  ossium  or  softness  of  the  walls  of  this  cavity, 
are  such,  as  not  to  be  easily  mistaken  for  those  of  any  other  affec- 
tion. In  this  disease,  the  walls  of  the  sinus  yield  to  pressure,  and 
regain  their  former  shape  when  the  pressure  is  removed.  Its 
existence,  therefore,  may  always  be  known  by  these  signs,  and  as 
these  are  sufficient,  it  is  not  necessary  to  enumerate  any  of  the 
others  by  which  it  is  characterized.  But  caries  and  necrosis  not 
being  so  easily  detected,  often  make  considerable  progress 
before  their  existence  is  ascertained.  The  fetor  and  appear- 
ance of  the  matter  discharged,  do  not  always  furnish  a diagnosis 
that  can  be  relied  upon,  inasmuch  as  some  of  the  diseases  that 
occur  within  this  cavity,  cause  its  secretions  to  become  equally 
as  offensive,  as  the  sanies  resulting  from  caries  or  necrosis,  and 
not  unlike  it  in  appearance.  Their  existence  however  may  in 
most  instances  be  inferred,  from  the  discharge  of  a dark-coloured 
fetid  sanies,  but  the  exfoliation  of  pieces  of  bone  will  set  al^ 
doubt  at  vest. 

Caries  or  necrosis  may  often  be  detected  by  perforating  the 
antrum  and  exposing  the  denuded  or  diseased  bone,  or  when 


OF  ITS  BONY  PARIETES. 


107 


there  is  an  external  opening,  by  probing  it.  In  this  way  any  loose 
or  dead  bone  may  be  felt  with  the  instrument ; and  the  diagnosis 
in  either  case  will  be  satisfactory. 

When  caries  or  necrosis  is  situated  in  the  alveolar  border,  or 
floor  of  the  antrum,  its  existence  can  be  more  readily  ascertained. 
The  occurrence  of  either  in  the  alveolar  ridge,  causes  the  gums 
to  inflame,  and  to  assume  a dark  purple  or  livid  appearance,  to 
separate  from  the  sockets  of  the  teeth,  and  frequently  to  slough  off 
in  large  pieces  and  expose  the  caried  or  necrosed  bone.  When 
situated  in  the  floor  of  the  antrum,  the  rough  denuded  bone  may 
be  easily  felt  with  a probe  or  stilet,  introduced  through  the  fistula 
.n  the  gums  or  alveolus  of  a tooth  from  which  the  matter  is  dis- 
charged. 

The  pain  accompanying  these  affections  does  not  constitute  a 
diagnosis  of  much  importance,  since  this  is  said  not  to  belong  to 
the  osseous  tissue,  but  to  the  soft  parts  that  cover  it. 

Causes. — Caries,  necrosis  and  other  alterations  of  the  osseous 
walls  of  the  maxillary  sinus  are  thought  by  some,  to  result,  very 
frequently,  from  certain  specific  or  constitutional  vices  ; such  for 
example,  as  the  venereal,  scorbutic,  scrofulous,  cancerous,  &c. 
independently  of  any  previous  morbid  condition  of  the  soft  parts. 
But,  I have  yet  to  be  convinced,  that  disease  ever  occurs  in  an 
osseous  tissue,  except  in  the  teeth,  while  the  soft  parts  in  contact 
with  it,  are  in  a healthy  state.  I am  of  the  opinion  therefore,  that 
the  contrary  supposition  is  gratuitous.  A bad  habit  of  body  or 
constitutional  vice,  may  perhaps,  increase  the  susceptibility  of  the 
bony  tissues  of  the  body  to  morbid  impressions,  but  I do  not 
believe  that  it  ever  gives  rise,  independently  of  the  condition  of 
the  soft  parts  with  which  they  are  connected,  to  actual  disease  in 
them. 


108  OP  CARIES,  NECROSIS  AND  SOFTENING 

The  immediate  cause  of  caries  and  necrosis  of  the  osseous  walls 
of  the  antrum  maxillare,  is  the  destruction  of  their  periosteum, 
caused  by  inflammation  or  ulceration;  and  these  last  may  result 
from  a purulent  condition  of  the  secretions  of  the  mucous  mem- 
brane of  this  cavity,  engorgement,  abscess,  or  from  the  presence 
of  foreign  bodies  or  tumours,  a blow  upon  the  cheek  or  from  other 
kinds  of  mechanical  violence.  They  may  also  result  from  the 
irritation  produced  by  diseased  teeth,  but  the  pressure  of  incarce- 
rated fluids  may  perhaps  be  regarded  as  the  most  frequent  cause; 
and  from  this  too,  results  some  of  the  most  aggravated  forms  of 
disease  that  ever  attack  the  maxillary  sinus. 

A morbid  action  kept  up  in  the  periosteum  for  a long  time,  by 
ulceration  of  the  lining  membrane,  or  any  other  aggravated  form 
of  disease  in  the  sinus,  or  neighbouring  soft  parts,  is  apt,  especially 
in  bad  habits,  to  result  in  caries  of  the  bone,  but  when  the  inflam- 
mation is  so  severe  as  to  cause  the  immediate  destruction  of 
the  periosteal  tissue,  necrosis  at  once  takes  place. 

The  softening  of  the  bone  seems  to  be  the  result  of  the  action  of 
some  solvent  fluid  upon  it,  capable  of  decomposing  or  breaking 
down  its  calcareous  molecules.  And,  although  inflammation  and 
ulceration  are  always  present,  and  appear  necessary  to  the  exu- 
dation of  this  fluid,  its  production  nevertheless,  seems  to  be  depen- 
dent upon  some  peculiar  state  or  habit  of  body. 

Thus,  it  is  from  other  affections  of  this  cavity,  that  those  now 
under  consideration  are  attributable. 

Treatment. — Complicated,  as  are  most  frequently,  caries,  ne- 
crosis and  other  alterations  of  the  osseous  walls  of  the  maxillary 
sinus,  with  other  affections  of  this  cavity,  their  cure  is  often  diffi- 
cult and  generally  tedious.  The  first  indication  to  be  fulfilled 


OF  ITS  BONY  PARIETES. 


109 


however  in  their  treatment,  as  in  the  case  of  engorgement,  and  of 
a muco-purulent  condition  of  the  secretions  of  the  sinus,  is  to  ob- 
tain free  egress  for  any  fluids  which  may  have  accumulated  in  it, 
and  this  should  be  effected  in  the  manner  as  before  described,  by 
the  extraction  of  a molaris  or  bicuspis,  and  the  perforation  of  the 
base  of  the  cavity  through  its  socket.  In  addition  to  this,  if  the 
disease  of  the  osseous  tissue  be  complicated  with  any  other  affec- 
tion of  the  sinus,  the  means  necessary  for  the  cure  of  the  disease 
with  which  it  is  complicated,  should  at  once  be  employed.  But 
it  is  not  necessary  here  to  describe  the  treatment  of  the  other 
diseases  of  this  cavity;  inasmuch  as  that  has  already,  or  will 
hereafter  be  done. 

Deschamps,  in  treating  upon  the  affections  of  the  osseous  walls 
of  this  cavity,  after  stating  that  the  perforation  or  opening  into  it 
should  be  large  enough  to  expose  the  seat  of  the  disease,  recom- 
mends the  employment  of  detersive  and  stimulating  injections,  a 
decoction  of  quinine,  tincture  of  myrrh  and  aloes,  &c.  &c. 
These  last,  he  says,  may  be  introduced  into  the  antrum  as  injec- 
tions or  by  means  of  pledgets  moistened  in  them.  He  also  directs 
the  cavity  to  be  “cleared  of  all  foreign  matter  which  may  have 
obtained  admission  into  it.,,#  This  treatment,  having  a tendency 
to  promote  a healthy  action  in  the  lining  membrane  of  the  sinus, 
will  often  be  all  that  is  required ; but  it  should  be  continued  until 
the  caried  or  necrosed  bone  has  exfoliated,  and  the  secretions  of 
the  antrum  cease  to  exhale  an  offensive  odor.  The  dead  bone, 
however,  having  exfoliated,  a cure  is  generally  soon  effected. 

But  it  sometimes  happens  that  the  disease  of  the  bone  has  been 
produced  by  some  very  malignant  and  incurable  affection  of  the 
* Maladies  des  Fosses  Nazales,  chap.  iv.  p.  279. 


110  OF  CARIES,  NECROSIS  AND  SOFTENING 

soft  parts;  in  that  case,  the  resources  of  art,  will  of  course,  prove 
unavailing.  And,  when  the  disease  of  the  bone  has  extended  itself 
lo  the  greater  part  of  the  superior  maxillary  and  the  bones  with 
which  it  is  connected,  as  for  example,  the  nasal,  palatine,  orbital, 
&e.  the  most  that,  can  be  hoped  for,  from  the  skill  of  the  physician, 
is  a palliation  of  the  symptoms.  Art,  in  such  cases,  can  seldom 
if  ever  effect  a cure,  and  there  are  other  cases  in  which  it  can 
only  retard  the  progress  of  the  disease,  or  assist  nature  in  her 
efforts  to  separate  the  dead  from  the  living  bone. 

It  is  impossible  to  lay  down  rules  for  the  treatment  of  altera- 
tions of  the  walls  of  the  maxillary  sinus,  from  which  it  will  not  be 
necessary  occasionally  to  deviate.  But,  it  will  be  sufficient  to 
state,  that  in  those  cases  where  they  are  extensively  involved  in 
caries  or  necrosis,  it  will  be  proper,  in  addition  to  perforating  the 
base  of  the  sinus,  if  by  this  means  the  dead  bone  cannot  be  so 
exposed  as  to  enable  the  surgeon  to  detach  it  from  the  living,  to 
cut  away  the  whole  of  the  alveolar  border  beneath  the  cavity,  or 
to  penetrate  the  sinus  above  it,  or  even,  as  Deschamps  recommends, 
“through  the  cheek  itself,  whether  there  be  an  ulcer  penetrating 
these  parts  or  not.”  Having  by  this  means  exposed  the  necrosed 
bone,  it  should  be  carefully  detached  from  that  which  is  sound, 
and  removed.  By  this,  the  disease  interiorly  will  be  more  fully 
exposed,  and  a better  opportunity  afforded  for  applying  such 
other  remedies  as  its  peculiar  nature  may  call  for.  It  is  impor- 
tant that  the  sinus  should  be  kept  clean,  and  that  the  air  be  kept 
from  it,  and  whenever  any  loose  pieces  of  bone  are  discovered, 
they  should  be  removed,  but  their  exfoliation  should  not,  as  is 
justly  remarked  by  the  author  last  quoted,*  be  hastened,  by  impro- 
*Traite  des  Maladies  des  Fosses  Nazales,  chap.  iv.  p.  281. 


OF  ITS  BONY  PARIETES. 


Ill 


per  interference,  unless  the  state  of  the  patient’s  health  be  such  as 
to  render  it  absolutely  necessary,  for  by  so  doing,  a piece  of  bone 
that  is  still  attached  to  the  soft  parts  may  be  broken.  But  while 
this  should  be  carefully  avoided,  all  dead  pieces,  isolated  from  the 
soft  parts,  should  be  detached  from  the  sound  bone  with  which  it 
may  be  connected,  and  removed. 

The  character  which  the  affections  of  this  cavity  put  on,  being 
determined  by  the  state  of  the  constitutional  health,  or  some  par- 
ticular vice  of  body,  it  often  becomes  necessary  in  their  treatment 
to  have  recourse  to  general  remedies.  If  the  subject  be  of  a 
scrofulous  or  scorbutic  habit,  or  is  affected  with  any  specific  con- 
stitutional vice,  such  remedies  as  are  indicated  by  the  affection  of 
the  general  system  under  which  he  may  be  labouring,  should  be 
employed.  But  it  is  not  necessary  here  to  describe  the  signs  by 
which  the  various  habits  of  body  and  constitutional  vices  are 
designated,  nor  is  it  essential  to  point  out  the  curative  treatment 
respectively  required  by  each.  Full  and  ample  directions  upon 
these  subjects  will  be  found  in  works  devoted  especially  to  the 
affections  of  the  general  system. 

But  although  the  character  and  malignancy  of  the  disease  are 
determined  by  the  state  of  the  constitutional  health,  or  disposition 
of  body,  its  occurrence  seems  nevertheless,  to  be  dependent  upon 
local  irritation.  Its  continuance  also,  in  many  instances,  results 
from  this;  and  the  cure,  in  cases  of  this  kind,  soon  follows  the 
removal  of  the  cause  that  gave  rise  to  it.  In  a case,  the  history 
of  which  I am  now  about  to  detail,  an  example  of  this  sort  is 
furnished. 

Case  XX.  L.  S — , a maiden  lady  of  about  thirty  years  of  age, 
of  a scorbutic  habit,  had  been  affected  with  pain  in  her  left  cheek 


112 


OF  CARIES,  NECROSIS  AND  SOFTENING 


and  alveolar  ridge  of  the  upper  jaw  of  the  same  side,  for  nearly 
two  years;  which  at  times,  had  been  almost  insupportable. 
Nearly  all  of  her  teeth  were  affected  with  caries,  and  from  be- 
tween the  necks  of  several,  on  the  left  side  in  the  superior  maxil- 
lary and  gums,  a fetid  sanies  had  been  exuding  for  two  or  three 
months.  Her  appetite  had  become  greatly  impaired,  and  a tumour 
half  the  size  of  a black  walnut,  having  formed  upon  the  palatine 
arch  of  the  affected  side,  she  became  alarmed,  and  in  the  fall  of 
1840,  came  from  her  residence  on  the  Eastern  Shore  of  Mary- 
land, to  Baltimore,  in  pursuit  of  medical  aid.  She  appplied  to 
Professor  T.  E.  Bond,  who,  after  investigating  her  case,  and 
satisfying  himself  that  the  affection  of  the  face  and  mouth  was 
the  result  of  the  diseased  condition  of  her  teeth,  advised  her  to 
place  herself  under  my  care;  which  she  did,  on  the  following  day. 

The  alveoli  of  four  of  the  teeth  of  the  affected  side,  in  the 
superior  maxillary,  were,  on  examination,  found  to  be  in  a necro- 
sed condition,  as  was  also  a part  of  the  palatine  bone  of  the  same 
side.  The  gums  around  these  teeth  had  separated  from  the  alve- 
olar processes,  and  had  a dark  livid  appearance.  A thin  dark 
coloured,  ichorous  matter,  which  when  brought  in  contact  with 
silver,  almost  instantly  turned  it  black,  was  constantly  exuding 
from  between  them  and  the  necks  of  the  teeth.  The  left  nostril 
was  dry,  and  the  opening  from  the  sinus  into  it  had  evidently 
closed,  but  an  exceedingly  fetid  matter  had  been  discharged  from 
it  during  the  early  stages  of  the  disease.  The  tumour  which 
had  formed  on  the  left  side  of  the  arch  of  the  palate,  wras  soft  and 
elastic.  When  pressed,  a dark  coloured  sanies  was  discharged 
from  the  alveoli,  and  it,  for  a time,  disappeared. 

The  alveolar  processes  being  in  a necrosed  and  loose  condition, 


OF  ITS  BONY  PARIETES. 


113 


it  was  with  some  difficulty  that  I succeeded  in  removing  the 
bicuspides  and  the  first  and  second  superior  molares  of  the  left 
side,  without  bringing  their  sockets  away  with  them.  The  opera- 
tion was  followed  by  the  discharge  of  a considerable  quantity  of 
fetid  sanies;  and,  in  a few  days,  the  alveoli  having  become  com- 
pletely detached  from  the  sound  bone,  I removed  them,  to- 
gether with  a part  of  the  floor  of  the  antrum.  The  opening 
thus  formed  into  this  cavity  was  large  enough  to  admit  the  end  of 
the  forefinger.  Several  small  pieces  of  bone  were  afterwards 
exfoliated,  from  where  the  teeth  had  been  extracted,  and  three 
pieces  from  the  left  side  of  the  palatine  arch. 

Without  any  other  treatment,  the  place  from  which  the  teeth 
and  alveoli  had  been  removed,  except  the  opening  that  communi- 
cated with  the  maxillary  sinus,  had  in  about  seven  weeks  be- 
come entirely  covered  with  fjrm  and  healthy  granulations.  But 
from  the  opening  into  the  antrum,  a fetid  matter  was  still  dis- 
charged. This,  however,  became  less  and  less  offensive,  until  at 
the  expiration  of  six  or  eight  weeks  more,  the  opening  into  the 
nose  having  become  re-established,  it  lost  its  fetid  odor,  and  the 
aperture  at  the  base  of  the  sinus  soon  after  closed. 

Thus,  in  a little  more  than  three  months,  a complete  cure  was 
effected.  The  patient  left  the  city  in  the  following  spring  and  I 
have  not  since  heard  from  her. 

The  history  of  the  two  following  cases  is  taken  from  Borde- 
nave’s  Observations  on  the  diseases  of  the  antrum  maxillare,  as 
published  in  the  “Memoirs  of  the  Royal  Academy  of  Surgery 
and  although  in  its  translation  as  here  presented,  it  is  considerably 
abridged,  no  important  fact  connected  with  either,  has  been 
omitted. 

* Obs.  xix.  and  xx.  vol.  xii,  12mo.  pages  61  and  64. 


14 


114 


OF  CARIES,  NECROSIS  AND  SOFTENING 


Case  XXI. — A ribbon-weaver,  sometime  after  having  receiv- 
ed a blow  upon  the  left  cheek  below  the  eye,  experienced  pain  in 
his  teeth  ; which  w'as  followed  by  swelling  of  the  cheek  and  the 
formation  of  a tumour  beneath  the  orbit,  where  he  had  received 
the  blow.  These  symptoms  yielded  to  general  treatment,  but  in 
about  a month  after,  the  swelling  returned,  which  was  supervened 
by  fever,  and  a discharge  of  acrid  serous  matter  in  the  mouth. 
These  were  followed  by  the  formation  of  a tumour  of  the  palate, 
from  which  a large  quantity  of  fetid  matter  was  discharged — an 
offensive  bieath,  and  the  removal,  by  an  operation  of  the  economy, 
of  two  roots  of  teeth  and  one  sound  tooth.  In  1760,  Bordenave 
took  charge  of  the  patient,  and  on  examination,  found  his  gums 
tumefied,  black  and  nearly  mortified.  The  flesh,  he  says,  had  sepa- 
rated from  the  palate  bone,  and  the  vitality  of  the  parts  was 
nearly  destroyed.  The  countenance  of  the  patient  had  a leaden 
aspect.  These  symptoms,  together  with  an  inspection  of  the 
parts,  induced  M.  Bordenave  to  suspect  a disease  of  the  antrum, 
complicated  with  a scorbutic  vice. 

Having  satisfied  himself  with  regard  to  the  nature  of  the  affec- 
tion, he  laid  bare  the  decayed  bones,  and  dressed  them  in  a proper 
manner.  Anti-scorbutics  were  prescribed,  and  injections  were 
employed,  which  passed  through  into  the  nose.  The  matter  soon 
became  less  abundant  and  of  a better  quality.  The  general 
health  of  the  patient  at  the  same  time  improved,  and  the  secre- 
tions of  the  antrum  were  in  part  discharged  through  the  nose. 
At  the  expiration  of  about  six  weeks,  the  exfoliation  of  nearly  the 
whole  of  the  alveolar  portion  of  the  superior  maxillary,  took 
place.  He  could  now  introduce  his  fingers  into  the  sinus.  Several 
small  pieces  of  bone  were  afterwards  exfoliated,  and  by  a proper 


OP  ITS  BONY  PARIETES. 


115 


course  of  treatment,  the  fleshy  portions  of  the  palate,  together 
with  the  adjoining  parts  united  and  closed  the  opening  into  this 
cavity.  In  a little  more  than  seven  months  a complete  cure  was 
effected. 

Case  XXII. — A man,  whose  right  superior  maxillary  at  the 
upper  part,  had  been  swollen  for  about  three  months,  had  at  the 
same  time,  a soft  tumour  on  the  interior  of  the  palate,  which,  on 
being  pressed,  caused  matter  to  be  discharged  from  the  nostril  of 
that  side.  These  affections,  together  with  tumefaction  of  the 
gums,  looseness  of  several  of  the  teeth,  and  a fetid  breath,  induced 
M.  Planque,  under  whose  care  the  patient  was  placed,  to  suspect 
suppuration  of  the  maxillary  sinus,  complicated  with  a scorbutic 
diathesis  of  the  general  system.  The  molares,  which  only  ad- 
hered to  the  gums,  having  been  extracted,  matter  was  discharged 
through  their  alveoli.  A portion  of  the  maxillary  bone  was  now 
discovered  to  be  carious,  and  this,  in  about  a month  began  to 
loosen,  and  a piece  about  an  inch  and  a half  long,  and  half  an 
inch  in  width,  some  time  after  exfoliated.  The  tumour  exteriorly 
disappeared;  the  walls  of  the  sinus  approximated,  and  a cicatrix 
ultimately  closed  the  opening  into  this  cavity. 

The  details  of  many  similar  cases  are  on  record,  but  it  would 
be  extending  the  limits  of  this  paper  too  far,  to  introduce  them 
here.  The  history  of  the  cases  already  given,  will  suffice  to 
illustrate  the  treatment  of  affections  of  this  description.  I should 
however,  have  given  the  history  of  one  of  mollifies  ossium  of  the 
walls  of  this  cavity,  had  T not,  while  treating  of  ulceration  of  the 
lining  membrane,  quoted  a case  in  which,  that  affection  had 
become  complicated  with  this. 

It  sometimes  happens  that  when  a very  large  opening  has 


116 


OF  CARIES,  NECROSIS,  &o 


been  formed  through  the  inferior  part  of  this  cavity,  it  does  not 
always  readily  close.  This,  however,  does  not  often  occur, 
except  the  natural  opening  has  become  obliterated.  But,  when 
the  parts  do  not  manifest  a disposition  to  unite,  the  practice  intro- 
duced by  Bordenave  and  Scultet,*  which  consists  in  cauterizing 
the  interior  circumference  of  the  opening,  will,  in  most  instances, 
prove  successful.  If,  however,  this  and  all  other  means  fail,  the 
opening  should  be  closed  by  means  of  an  obturator  of  fine  gold. 
This  should  be  accurately  fitted  to  the  parts,  and  secured  by 
means  of  a broad  clasp,  to  a molar  or  bicuspid  tooth,  and  if  there 
be  none  suitable  on  the  side  of  the  mouth  to  which  it  is  to  be 
applied,  the  gold  should  be  extended  to  one  on  the  opposite  side. 
If  it  be  necessary  to  replace  the  teeth  that  have  been  lost,  with 
artificial  ones,  these  may  be  so  mounted  that  the  plate  upon  which 
they  are  set,  shall  cover  the  opening  into  the  maxillary  sinus,  and 
thus  obviate  the  necessity  of  any  other  obturator. 

* Vide,  Memoirs  de  l’Academie  Royale  de  Chirurgie,  12rno.  vol.  12,  p.  82. 


CHAPTER  VII. 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE  AND  PERIOS- 
TEUM. 

The  lining  membrane  and  periosteal  tissue  of  the  maxillary 
sinus  occasionally  become  the  seat  of  fungous  and  other  descrip- 
tions of  tumours,  and  in  consequence  of  the  concealed  situation  of 
this  cavity,  morbid  productions  originating  in  it,  often,  as  has  been 
previously  remarked,  make  considerable  progress  before  they 
attract  attention ; and  hence,  the  efforts  of  art  for  their  cure, 
which  might  otherwise  frequently  be  successful,  in  most  instances 
prove  unavailing.  The  presence  of  a tumour  in  this  cavity  may 
give  rise  to  all  the  diseases  to  which  its  osseous  walls  are  liable, 
as  well  also  as  to  most  of  those  that  are  incident  to  its  soft  tissues. 
As  soon  as  a morbid  growth  here,  has  filled  the  sinus,  it,  as  it 
continues  to  augment  in  size,  presses  upon  the  lining  membrane, 
and  excites  in  it  imflammation  and  sometimes  ulceration,  and 
causes  its  secretions  to  become  vitiated.  A diseased  action  is 
communicated  to  the  periosteum  of  the  surrounding  osseous  walls; 
it  ceases  to  furnish  them  with  the  healthy  juices  which  they  re- 
quire for  their  preservation,  thickens,  ulcerates,  and  is  at  once 
destroyed,  or  exudes  a corrosive  fluid.  The  bony  parietes  of 
the  sinus  are  soon  softened  or  become  affected  with  caries  or 
necrosis,  and  one  or  more  fistulous  openings  are  formed  through 
the  cheek,  alveoli,  or  palatine  arch. 


118 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE 


But  these  are  not  the  only  effects  that  result  from  tumours 
situated  in  this  cavity.  As  they  increase  in  volume,  alter  having 
filled  the  sinus,  they  gradually  distend  and  displace  its  bony  parie- 
tes  ; the  floor  of  the  orbit  is  sometimes  elevated,  and  the  eye  more 
or  less  forced  from  its  socket;  the  palatine  arch  and  alveolar  ridge 
are  depressed,  the  teeth  loosened  and  caused  to  drop  out,  and  when 
the  tumour  is  of  a soft  fungous  nature,  it  not  unfrequently  escapes 
through  the  alveoli  into  the  mouth,  and  after  forcing  the  jaws 
asunder  to  their  greatest  extent,  protrudes  from  it  in  enormous 
masses.  Bertrandi  gives  the  history  of  a case  of  polypus  excres- 
cence of  the  antrum,  which  after  having  destroyed  the  palate, 
anterior  part  of  the  maxillary  bone,  and  filled  the  mouth,  forced 
itself  up  into  the  orbit,  elevated  its  roof,  pressed  upon  the  brain, 
and  ultimately  occasioned  apoplexy  and  death.*  Other  similar 
cases  are  on  record.  Mr.  Cooper  says  there  are  three  specimens 
of  diseased  antrum  in  the  museum  of  London  University  College. 

The  tumour  in  two  of  these,  had  “made  its  way  from  the  antrum 
to  the  brain.”  The  third  was  taken  from  a patient  of  his,  which 
had  died.  The  tumour  in  this  case,  which  was  of  a medullary  and 
scirrhous  character,  forced  itself  up  into  the  orbit,  displaced  the 
eye,  and  ultimately  caused  the  death  of  the  patient.  The  same 
author  mentions  another  case,  the  subject  of  which  was  a boy  in 
St.  Bartholomew’s  Hospital,  who  had  a tumour  of  the  antrum 
which  “made  its  way  through  the  orbiter  plate  of  the  frontal  bone 
and  cribriform  plate  of  the  ethmoid  into  the  cranium,”  and  though 
the  portion  of  it  that  entered  the  brain  was  as  large  as  a small 

* Vide,  Traite  de  ses  Operations  Chirurgicales,  p.  369. 


AND  PERIOSTEUM. 


119 


orange,  he  says  the  boy  was  only  in  a comatose  state  about  forty- 
eight  hours  previously  to  his  death.* 

Tumours  occupying  the  maxillary  sinus  do  not  always  originate 
in  its  lining  membrane  or  periosteum.  They  sometimes  arise 
from  the  pituitary  membrane  of  the  nose,  frontal  sinus,  or  eth- 
moidal cells,  and  after  having  found  their  way  into  this  cavity, 
augment  in  size,  until  they  produce  the  effects  just  described. 
Some  suppose  that  the  morbid  productions  found  here,  originate 
more  frequently  in  the  cells  of  the  ethmoid  bone,  than  in  the 
lining  membrane  of  this  cavity  ;f  but  I am  disposed  to  believe 
that  this  opinion  is  not  well  founded,  and  that  it  has  chiefly  resulted 
from  the  great  liability  of  most  kinds  of  tumours  of  the  maxillary 
sinus,  to  be. reproduced  after  having  been  extirpated, — which  is 
often  attributable  to  the  continuance  of  the  cause  that  gave  rise 
to  them  in  the  first  instance,  or  to  their  imperfect  removal.  That 
they  do  however  sometimes  originate  in  the  ethmoidal  cells,  there 
can  be  no  question. 

It  sometimes  happens  that  tumours  having  their  seat  in  the 
antrum,  after  having  filled  it,  make  their  way  into  the  nose,  where 
they  acquire  a size  equal  to,  or  even  greater  than  that  to  which 
they  had  previously  attained  here,  thus  dividing  themselves,  as  it 
were,  into  two  parts — one  occupying  this,  and  the  other,  one  of 
the  nasal  cavities.  Occurrences  of  this  sort  are  not  unfrequent, 
and  they  sometimes  lead  to  the  adoption  of  an  incorrect  opinion, 
with  regard  to  the  real  seat  of  the  disease.  Thus,  a polypus  of 
the  antrum  is  occasionally  mistaken  for  one  of  the  nose,  and  the 

* Vide  Professor  Reese’s  Appendix  to  Cooper’s  Surgical  Dictionary, 
American  edition  of  1842,  page  29. 

t Vide  Traite  des  Maladies  de  la  Bouch,  t.  i.  p.  210,  &.c. 


120 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE 


error  frequently  not  discovered,  until  an  attempt  is  made  to  re- 
move it. 

The  character  of  morbid  growths  in  this  cavity  is  exceedingly 
variable,  as  much  so  as  is  the  state  of  the  constitutional  health  of 
different  individuals,  and  the  causes  that  give  rise  to  them.  They 
not  only  vary  in  their  appearance  and  structure,  but  they  vary  in 
their  malignancy.  Some  are  of  a healthy  flesh  colour,  soft,  sensi- 
ble, but  not  painful,  and  present  a smooth,  regular  surface;  others 
varying  in  their  consistence  from  hard  to  soft,  and  in  their  colour 
from  a pale  yellow  to  a deep  red  or  purple,  present  a rough, 
irregular,  and  not  unfrequently  ulcerated  surface,  and  are  more 
or  less  sensitive  to  the  touch  and  painful.  Some  have  their  origin 
in  the  mucous  membrane,  and  others,  both  in  this,  and  the  perios- 
teum. Some  are  attached  by  a broad  base,  and  others,  it  is  said, 
are  connected  only  by  a mere  peduncle. 

But  as  it  regards  this  latter  description  of  tumours,  which  are 
usually  designated  by  the  name  of  polypi,  their  occurrence  in  the 
maxillary  sinus  is  questioned  by  some  writers.  Sir  Benjamin 
Brodie  does  not  believe  that  they  ever  form  in  this  cavity;*  and 
in  this  opinion  Mr.  S.  Cooper  fully  concurs ;f  but  that  they  are 
occasionally  met  with  here,  seems  nevertheless  to  be  pretty  con- 
clusively established.  A case  described  by  M.  Bertrandi  in  his 
treatise  on  Operative  Surgery,  page  369,  has  already  been  referred 
to,  and  Bordenave,  in  his  observations  on  the  diseases  of  the  an- 
trum maxillare,  gives  the  history  of  a case  treated  by  M. 

* Vide  London  Medical  Gazette,  for  December,  1834.  p.  850. 

fVide  Professor  Reese’s  Appendix  to  Cooper’s  Surgical  Dictionary, 
American  edition,  1842,  p.  29. 


AND  PERIOSTEUM. 


121 


Doublet.*  Rusch  declares  that  he  has  twice  seen  polypus  of  this 
cavity,  and  Petitt,  Levrette  and  other  writers  also  affirm  that 
they  have  witnessed  polypi  here.f  The  occurrence  then  of  polypi 
in  the  maxillary  sinus,  although  very  rare,  it  must  be  admitted 
does  sometimes  happen.  But  other  descriptions  of  tumours  are 
certainly  more  frequently  met  with  in  this  cavity.  Of  these, 
some  are  of  a simple  fibrous,  sarcomatous,  or  osteo-sarcomatous 
nature, J and  when  thoroughly  extirpated,  are  seldom  reproduced  ; 
others  are  of  a medullary,  cancerous,  or  carcinomatous  charac- 
ter. These  last,  although  originating  in  the  mucous  membrane, 
if  long  neglected,  are  very  liable  to  be  reproduced  after  their 
removal,  and  generally  occasion  the  death  of  the  patient. 

It  sometimes  happens  that  several  fungi,  and  from  opposite  and 
various  points  in  this  cavity,  spring  up.  The  chances  of  cure, 
when  this  is  the  case,  especially  if  they  are  of  a malignant  cha- 
racter, are  greatly  lessened. 

Tumours  in  the  maxillary  sinus  seldom  grow  very  fast  during 
the  early  stages  of  their  formation ; but,  as  they  enlarge,  the 
neighbouring  parts  become  involved  in  the  diseased  action,  and 
consequently  furnish  them  with  fluids  less  healthy  in  their  quali- 
ties, and  thus  cause  them  to  assume  a character  of  greater  ma- 
lignancy, and  generally  to  increase  more  rapidly  in  size. 

Having  premised  these  few  general  observations  on  tumours  of 
the  maxillary  sinus,  I shall  proceed  to  describe  the  principal 
signs  by  which  their  existence  here  is  indicated. 

* Vide  Mem.  de  l’Academie  Royale  de  Chirurg.  12mo.  t.  13,  p.  393. 

t Vide  Traite  des  Maladies  de  la  Bouch,  tom.  1,  p.  212,  and  sur  cure  des 
Polypes  de  la  matrice,  de  la  gorge,  et  du  nez,  page  253. 

\ Vide  Professor  Reese’s  Appendix  to  Cooper’s  Surgical  Dictionary, 
American  edition,  1842. 

15 


122 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE 


Symptoms. — The  occurrence  of  tumours  in  the  maxillary  sinus 
is  rarely  accompanied,  previously  to  their  having  obtained  a size 
sufficiently  large  to  fill  it,  by  symptoms  differing  materially  from 
those  occasioned  by  many  of  the  other  affections  that  locate 
themselves  here.  But,  after  they  have  filled  the  sinus,  the  indica- 
cations  soon  become  less  equivocal.  Swelling  of  the  cheek,  de- 
pression of  the  palatine  arch  and  alveolar  ridge,  loosening  of  the 
superior  molar  teeth  of  the  affected  side,  inflammation  and  spon- 
giness ot  the  gums,  elevation  of  the  floor  of  the  orbit,  and  pro- 
trusion or  concealment  of  the  eye,  are  symptoms  which  result  from 
the  presence  of  tumours  in  this  cavity,  but  they  are  not  peculiar 
to  these  affections  alone ; many  of  them  are  produced  by  mucous 
engorgement  of  the  sinus.  But  when  to  these  is  superadded  the 
discharge  of  a bloody  sanies  from  the  nose,  or  from  one  or  more 
fistulous  openings  through  the  cheek,  alveolar  ridge,  or  palatine 
arch,  the  diagnosis  will  be  conclusive;  and  the  existence  of  a 
tumour  in  the  antrum  will  then  be  established  beyond  doubt. 

There  are  also  other  signs  by  which  the  occurrence  of  a mor- 
bid growth  in  this  cavity  may  be  known;  as  for  example, — the 
dropping  out  of  the  superior  molares  of  the  affected  side,  and  the 
protrusion  of  portions  of  the  tumour  through  the  alveoli. 

The  pain  is  seldom  severe  until  the  tumour  has  filled  the  cavity, 
except  the  excrescence  be  from  its  inception  of  a malignant  cha- 
racter; but  as  it  augments  in  size  and  forces  the  walls  of  the  sinus 
asunder,  it  becomes  more  and  more  severe.  It  sometimes,  during 
the  progress  of  the  disease,  becomes  almost  excruciating.  In  a 
case  of  fungus  hsematodes  of  this  cavity,  which  the  author,  a few 
years  since,  had  an  opportunity  of  witnessing,  the  patient  was  in 
the  habit  of  taking  upwards  of  two  tea-spoonsful  of  black  drop  at 
a time,  for  the  procurement  of  ease  and  sleep. 


-AND  PERIOSTEUM. 


123 


But  in  addition  to  the  foregoing  symptoms,  several  of  the  affec- 
tions already  treated  on,  together  with  all  the  effects  produced  by 
them,  not  unfrequently  result  from  tumours  in  this  cavity.  In- 
flammation and  ulceration  of  its  lining  membrane,  a purulent 
condition  of  its  secretions,  and  caries,  necrosis  and  a softening  of 
its  osseous  walls,  seldom  fail  to  follow  some  of  the  stages  of  the 
formation  of  the  morbid  productions  now  under  consideration. 

The  symptoms  peculiar  to  each  variety  of  tumour,  it  is  not 
necessary  to  mention,  inasmuch  as  they  are  given  by  most  writers 
on  general  surgery. 

Causes. — Most  writers  on  the  affections  of  the  maxillary  sinus, 
are  of  the  opinion  that  tumours  in  this  cavity  result  spontaneously, 
as  a consequence  of  some  specific  constitutional  vice,  independent- 
ly of  local  causes.  I do  not  however  believe  that  they  are  ever 
thus  originated.  ■ But  that  a bad  habit  of  body  or  some  constitu- 
tional vice  is  necessary  to  the  production  of  the  affections  under 
consideration,  I do  not  doubt,  but  that  this  is  capable  of  giving 
rise  to  them  in  parts  uninfluenced  by  local  irritation,  I think  ex- 
ceedingly questionable.  Having  however  already  expressed  my 
views  with  regard  to  the  agency  exerted  by  particular  habits  of 
body  and  constitutional  vices  in  the  production  of  diseases  in  this 
cavity,  it  will  not  be  necessary  to  repeat  what  I have  before  said 
upon  the  subject.*  It  will  be  sufficient  to  remark  that  most,  if  not 
all  of  the  morbid  excrescences  here  met  with,  result  from  local 
irritation  and  constitutional  vices;  and  that  both  are  necessary  to 
their  production. 

Scorbutic  and  scrofulous  habits,  and  persons  whose  general 
health  has  been  impaired  by  certain  constitutional  diseases, — such 

* Vide  introductory  remarks,  pp.  17 — 22. 


124  OF  TUMOURS  OF  ITS  LINING  MEMBRANE 

as  the  venereal,  protracted  inflammatory  and  bilious  fevers,  dys- 
pepsia, &c.,  are  most  subject  to  tumours  of  the  maxillary  sinus ; 
but  every  thing  in  fact,  which  has  a tendency  to  increase  the 
irritabilty  of  the  soft  tissues  of  the  body  may  be  considered  as  so 
many  predisposing  causes.  The  local  causes  are  the  same  as 
those  of  most  of  the  other  morbid  affections  of  this  cavity. 
Diseased  teeth,  gums  and  alveolar  process  are  probably  among 
the  most  common.  The  irritation  produced  by  these  so  frequently 
extends  itself  to  the  antrum,  that  their  agency  in  the  production 
of  tumours  here,  cannot  be  questioned.  There  are,  however, 
other  causes  of  irritation  to  which  this  cavity  is  exposed,  such  for 
example,  as  blows  upon  the  cheek,  wounds,  &c. 

Treatment. — It  is  only  in  the  early  stages  of  the  formation  of 
tumours  in  the  maxillary  sinus,  that  surgical  treatment  can  be 
adopted  with  success,  and  even  then,  their  entire  extirpation  is 
necessary.  If  this  be  not  accomplished,  a speedy  return  of  the 
disease  may  be  expected.  But,  preparatory  to  the  removal  of  the 
diseased  structure,  a large  opening  should  be  made  into  the 
antrum,  so  as  to  expose  as  much  of  it  as  possible ; and  with 
regard  to  the  most  proper  place  for  effecting  this,  Deschamps, 
recommends  when  the  alveolar  ridge  has  been  started,  the  removal 
of  the  first  or  second  molaris,  and  the  perforation  of  the  sinus 
through  its  socket  with  a “three-sided  trocar  of  suitable  dimen- 
sions.” But  when  the  alveolar  ridge  and  teeth  are  sound,  he 
directs  the  opening  to  be  made  through  the  outer  wall  of  the  sinus 
above  the  ridge,  and  this  he  thinks,  on  account  of  its  being  more 
direct,  is  preferable  to  the  other  mode.*  An  opening  may  be 
easily  effected  in  either  way  into  the  sinus,  as  its  walls  are  gene- 
rally, so  much  softened  as  to  offer  but  little  resistance. 

*Malades  des  Fosses  Nazales,  sec.  ii.  art.  iv.  p.  244. 


AND  PERIOSTEUM. 


125 


When  the  opening  is  to  be  made  through  the  external  parietes, 
the  instrument  recommended  by  Mr.  Thos.  Bell,*  to  be  employed 
for  cutting  away  the  bone  after  it  has  been  exposed,  is  “a  strong 
hooked  knife,”  which  is  probably  as  well  adapted  to  the  purpose 
as  any  that  could  be  used.  Some  surgeons  employ  strong  curved 
scissors,  but  the  hooked  knife,  I should  think  preferable. 

A free  opening  having  been  effected  into  the  antrum,  a finger 
of  the  operator  should  be  introduced,  and  the  nature  of  the  dis- 
eased structure  ascertained.  This  done,  he  will  be  enabled  to  de- 
termine the  proper  procedure  tobe  had  recourse  to  for  its  removal. 
If  the  tumour  partakes  of  the  character  of  those  called  polypi,  it 
may  be  seized  with  a pair  of  forceps  and  torn  away,  but  if  it  be 
attached  by  a broad  base,  its  extirpation  will  be  most  readily 
effected  with  a knife.  But,  even  with  this,  it  is  often  exceedingly 
difficult  to  effect  its  total  removal,  so  that  it  not  unfrequently  be- 
comes necessary  to  employ  the  actual  cautery  ; for,  if  any  small 
portions  be  left  behind,  as  has  before  been  stated,  a reproduction 
of  the  disease,  will  generally  very  soon  take  place.  When  the 
disease  has  originated,  or  is  seated,  in  the  periosteum,  the  cautery 
has  proved  to  be  the  most«effectual  means  of  preventing  its  return 

of  any  that  has  been  tried.  The  French  surgeons  have  applied 

* 

it  with  great  success.  Desault,  in  a case  of  fungous  tumour, 
succeeded  in  effecting  a cure  after  three  applications.  The 
root  of  the  disease,  by  the  employment  of  this,  can  often  be 
destroyed/  when  less  effectual  means  would  fail.  But  it  is  im- 
portant when  it  is  had  recourse  to,  that  it  should  have  such 
a degree  of  heat,  as  to  accomplish  this  object  instantaneously 
else,  the  inflammation  that  would  otherwise  be  excited  by  its  ap- 
*Anat.  Phys.  and  Diseases  of  the  Teeth,  p.  282. 


126  OP  TUMOURS  OF  ITS  LINING  MEMBRANE 

plication  in  the  surrounding  parts,  would  greatly  retard,  if  it  did 
not  prevent  the  cure.  The  remarks  of  Mr.  Thos.  Bell  upon  this 
subject,  who  says,  “the  white  heat  should  be  employed,”*  are 
worthy  of  attention. 

In  remarking  upon  the  bold  practice  of  the  French  surgeons  in 
the  treatment  of  these  affections,  the  author  just  quoted  says,  it 
“Is  worthy  of  our  praise  and  imitation;”  and,  continues  he,  “the 
timidity  which,  until  very  lately,  almost  excluded  the  use  of  the 
actual  cautery  in  this  country,  has  been  one  cause,  and  that  a 
very  prevalent  one,  of  failure  in* the  treatment  of  some  of  these 
cases ; but  it  is  not  so  easy  to  account  for  the  still  more  culpable 
dread,  which  has  in  so  many  instances  prevented  any  attempt 
from  being  made  to  extirpate  the  disease ; a degree  of  pusillani- 
mity which  is  at  once  an  opprobrium  on  the  profession,  and  a 
fatal  injustice  to  the  sufferers,  who  thus  abandoned  to  the  unre- 
strained progress  of  the  disease,  are  left  to  perish  by  a lingering 
and  most  painful  process,  without  even  an  attempt  being  hazarded 
for  their  relief.” 

The  foregoing  comparison,  instituted  by  Mr.  Bell,  between  the 
practice  of  the  French  and  English  surgeons  in  the  treatment  of 

tumours  of  the  maxillary  sinus,  perhaps  is  correct;  but  it  is  due  to 

% 

truth  to  say,  that  the  bold  practice  of  the  former  has  been  fully  and 
successfully  emulated  by  American  surgeons.  Dr.  A.  H.  Stevens, 
Professor  of  Surgery  in  the  University  of  New  York,  in  1823,  in 
a case  of  fungous  tumour,  attached  by  a broad  base  to  the  lower 
part  of  the  antrum,  removed  a large  portion  of  the  lower  and  an- 
terior parts  of  the  upper  jaw.  The  patient  recovered  and  is  said 
to  be  living  at  the  present  time.f  In  1841,  Dr.  J.  C.  Warren,  of 

* Anat.  Phys.  and  Diseases  of  the  Teeth,  p.  282. 
f Appendix  to  Cooper’s  Surgical  Dictionary,  p.  30. 


AND  PERIOSTEUM. 


127 


Boston,  for  a case  of  cephalomratous  tumour  of  this  cavity,  re- 
moved the  superior  maxillary  bone.  This  operation  also,  was  suc- 
cessful.* The  same  operation  was  performed  soon  after,  and  for 
the  removal  of  a tumour  of  the  antrum,  with  success,  by  R.  D. 
Mussey,  of  Cincinnati,  Ohio.f 

But  the  operation  for  the  removal  of  the  superior  maxillary,  did 
not  originate  with  American  surgeons;  Velpeau  says  it  was  per- 
formed by  Acoluthus  in  1693,  for  a tumour  of  the  face.J  By  a 
reference  however,  to  the  history  of  the  case  as  given  in  a memoir 
of  the  Academy  of  the  Curiosities  of  Nature, ||  it  will  be  perceived 
that  the  tumour  originated  in  the  maxillary  sinus,  and  that  only  a 
part  of  the  jaw-bone  was  removed.  If  however,  we  can  believe 
Wiseman,  this  most  formidable  operation  was  performed  at  a still 
earlier  period.  He  says  in  his  surgery,  the  first  edition  of  which 
was  published  in  1676,  “That  he  cut  into  a man’s  cheek,  sawed  in 
pieces  the  alveolus,  and  took  out  the  whole  jaw,  and  cured  him.”§ 
But  although  the  operation  may  have  been  performed  thus  early, 
it  does  not  at  all  detract  from  the  credit  due  to  modern  surgeons, 
since  the  method  of  effecting  it,  is  at  least,  original  with  them. 

Thus  it  is  perceived,  that  the  diseases  under  consideration  not 
unfrequently  call  for  one  of  the  most  formidable  operations  in 
surgery,  and  that  by  it,  many  unfortunate  sufferers  have  been 
snatched,  as  it  were,  from  the  very  jaws  of  death.  But  notwith- 
standing the  performance  of  even  this  operation,  the  application  of 
the  cautery  often  becomes  necessary  to  prevent  a reproduction  of 

* Boston  Medical  and  Surgical  Journal  for  1842. 

f Western  Lancet  for  1842. 

J Velpeau’s  Operative  Surgery,  p.  263. 

1|  Decad  3,  ann.  4o.  Obs.  57. 

§ Vide  Wiseman’s  Surgery,  page  285. 


128 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE 


the  excrescence,  and  there  are  many  cases  in  which  it  cannot  be 
repressed  by  this.  The  result  of  the  most  thorough  and  best  di- 
rected treatment  depends  on  the  state  of  the  constitutional  health 
and  the  nature  of  the  disease.  In  depraved  habits  and  shattered 
constitutions,  if  the  tumour  be  of  a carcinamatous  character,  a 
cure  need  never  be  expected. 

The  hemorrhage,  during  the  operation  for  the  removal  of 
tumours  of  the  antrum,  is  sometimes  so  profuse  as  to  require  very 
prompt  and  active  means  to  arrest  it.  It  may  generally,  however, 
be  controlled  by  the  employment  of  compresses  and  suitable  styp- 
tics, but  should  these  fail,  the  actual  cautery  should  be  had  recourse 
to. 

The  history  of  the  following  cases,  promiscuously  taken  from 
various  works,  will  perhaps  furnish  a more  correct  idea  of  the 
methods  of  treatment  most  proper  to  be  pursued,  than  any  descrip- 
tion which  could  otherwise  be  given.  The  first  four  cases  are 
taken  from  the  Memoirs  de  1’Academie  Royale  de  Chirurgie.* 

Case  XXIII. — A man  about  thirty-five  years  of  age,  had  a 
fleshy  tumour  about  the  size  of  a large  pea,  situated  in  a space 
formed  by  the  decay  of  the  first  and  second  superior  molares  of 
the  left  side.  This  tumour  caused  a dull  pain;  it  was  excised, 
and  the  actual  cautery  applied  to  arrest  the  bleeding  and  destroy 
remaining  portions  of  the  excrescence.  It  re-appeared,  and  three 
months  after  was  double  the  size  of  the  former,  and  impeded  mas- 
tication. The  two  decayed  teeth  were  loose  and  the  others  were 
painful ; and  a fetid  matter  escaped  through  the  nose  and  mouth. 

After  the  extraction  of  the  two  decayed  teeth,  M.  Dubertrand, 
discovering  that  the  tumour  had  its  seat  in  the  antrum,  seized 
it  with  polypi  forceps  and  brought  the  whole  of  it  away.  After 
* Tome  13,  obs.  1,  5 and  7th,  pages  372,  387,  393  and  424. 


AND  PERIOSTEUM. 


129 


the  extraction  of  the  tumour,  the  opening  through  the  alveolus 
was  large  enough  to  admit  the  little  finger.  M.  Dubertrand  next 
destroyed  such  portions  of  the  alveoli  and  maxillary  bone  as  were 
decayed.  But  after  the  extirpation  of  the  tumour,  he  found  it 
necessary  to  introduce  a plug  of  cotton  into  the  antrum,  to  arrest 
the  hemorrhage  that  followed  the  operation. 

The  secretions  of  the  maxillary  sinus  ceased  to  exhale  an  un- 
pleasant odour,  in  three  days  they  became  healthy,  and  in  less 
than  one  month,  the  patient  was  restored  to  health,  and  the 
opening  from  the  mouth  into  this  cavity  was  closed  with  firm 
granulations. 

The  tumour  just  described  was  of  the  simplest  kind,  but  had  it 
not  been  completely  eradicated,  it  would  doubtless  have  soon 
reappeared. 

Case  XXIV. — Acoluthus,  reports  the  case  of  a woman  thirty 
years  of  age,  who  in  1693,  came  to  Pologne  in  Silesia,  in  search 
of  aid  for  a peculiar  disease  of  the  antrum,  under  which  she  was 
labouring.  Some  time  after  the  extraction  of  a tooth  from  the 
left  side  of  the  upper  jaw,  a small  tumour  appeared  in  its  alveolus, 
and  it  made  such  progress,  that  in  two  years,  it  attained  the  size 
of  a double  fist.  It  occupied  nearly  the  whole  cavity  of  the  mouth, 
and  distended  the  jaw  to  such  a degree  that  it  was  feared  it  would 
rupture  it.  The  lower  jaw  was  depressed,  the  lips  could  not  be 
made  to  meet,  and  the  tumour  increased  so  fast,  that  in  a few 
weeks,  the  woman’s  life  was  despaired  of — she  being  threatened 
with  suffocation,  hunger  and  thirst.  Under  these  circumstances, 
Acoluthus  determined  to  attempt  a cure. 

The  tumour  was  very  hard  and  occupied  the  greatest  part  of 
the  palatine  arch ; the  upper  teeth  of  the  left  side  were  in  its 
16 


130 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE 


centre.  The  operation  was  commenced  by  enlarging  the  mouth, 
beginning  at  the  commissure  of  the  lips,  and  passing  it  transversely 
through  the  cheek.  This  enabled  Acoluthus  to  attack  the  exterior 
of  the  tumour  with  a curved  bistoury.  The  excrescence  was  as 
hard  as  cartilage  and  scarcely  yielded  to  cutting  instruments  ap- 
plied by  a strong  hand.  He  however  succeeded  in  bringing  three 
or  four  teeth  together  with  a portion  of  the  superior  maxillary 
bone.  But  the  operation  as  yet  had  extended  only  to  the  exterior 
half  of  the  tumour;  the  other  which  filled  the  palatine  fossae,  he 
says,  it  was  impossible  to  bring  away.  The  removal  of  that  was 
effected  only  by  piece-meal  and  at  different  times.  The  operation 
was  long,  laborious  and  very  painful.  The  actual  cautery  was 
applied  to  the  bleeding  vessels  and  fungous  flesh.  The  appearance 
of  the  patient,  a few  days  after  the  operation  was  such  as  to 
inspire  hope  for  a favourable  termination  of  the  disease.  The 
actual  cautery  was  applied  several  times,  and  finally  there  were 
no  indications  of  a reappearance  of  the  excrescence,  except  at  the 
point  where  it  had  first  originated.  Some  portions  of  bone,  were 
afterwards  found  to  be  carious,  and  the  removal  of  these  was 
followed  by  a prompt  and  speedy  cure. 

This  was  the  operation  alluded  to  by  Velpeau,  as  embracing  the 
removal  of  the  superior  maxillary,  previously  noticed,  but  from 
the  description  here  given  of  it,  it  would  appear  that  only  a small 
portion  of  the  bone  was  taken  away.  The  alveolar  ridge  and 
anterior  parietes  of  the  sinus  was  all  that  was  removed.  The 
history  of  the  case,  however  imperfect  as  it  is,  and  the  result  of  its 
treatment,  proves  that  the  resources  of  art  are  adequate  to  the 
cure  of  many  of  the  most  formidable  and  threatening  of  the  affec- 
tions of  this  cavity,  if  their  employment  be  not  delayed  too  long. 


AND  PERIOSTEUM. 


131 


Case  XXV. — In  1755,  M.  Doublet  was  consulted  by  a lady 
thirty-nine  years  of  age,  who  had  a tumour  the  size  of  a hazlenut 
at  the  internal  angle  of  the  left  eye,  upon  the  os  unguis.  This 
was  movable  and  hard,  but  the  patient  experienced  no  pain  from 
it.  Some  time  after  she  complained  of  difficult  respiration, 
through  the  left  nasal  cavity.  Upon  examination,  M.  Doublet 
discovered  a polypus  of  a soft  flabby,  consistency.  This  he 
thought  should  be  extracted  before  attempting  to  remove  the 
exterior  tumour,  which,  having  effected,  that  subsided  and  the 
patient  enjoyed  good  health  for  four  months.  At  the  expiration 
of  this  time,  a tumour  three-fourths  larger  than  the  first  made  its 
appearance,  which  was  extracted,  and  the  patient  again  remained 
well  for  one  month.  But  by  this  time,  another  polypus  had  made 
its  appearance  in  the  left  nostril,  softer  than  the  first.  This  was 
treated  by  escharotics,  and  some  time  after  a fourth  polypus  made 
its  appearance,  and  a fourth  tumour  showed  itself  at  the  angle  of  the 
eye.  The  progress  of  these  was  more  rapid  than  any  which  had 
preceded  them,  and  they  were  accompanied  by  violent  headache. 
The  patient’s  general  health,  notwithstanding  the  local  affection, 
was  good,  and  the  tumour  and  polypus  did  not  exhale  a fetid 
odour.  The  glands  of  the  mouth  were  swollen.  Alteratives  were 
prescribed  and  an  issue  was  opened.  These  appeared  to  give  the 
patient  some  relief,  but  the  tumour  at  the  angle  of  the  eye  not- 
withstanding made  such  progress,  and  the  maxillary  sinus,  which 
before  was  not  suspected  of  being  diseased,  became  so  completely 
filled,  that  the  palatine  process  of  the  maxillary  bone,  separated. 
This  was  followed  by  a considerable  swelling  of  all  the  internal 
membrane  of  the  mouth,  the  gums  became  hard  and  black,  and 
in  the  month  of  March,  1758,  the  patient  died. 


132  OF  TUMOURS  OF  ITS  LINING  MEMBRANE 

On  submitting  the  diseased  part  to  a post  mortem  examination, 
a large  tumour,  says  M.  Doublet,  was  found  in  the  antrum,  which 
completely  filled  it,  and  it  had  attained  double  this  size  under  the 
zygomatic  arch  and  near  the  angle  of  the  eye.  The  palatine 
process  of  the  maxillary  bone  was  pressed  out  about  the  width  of 
two  fingers  ; the  upper  row  of  teeth  were  displaced,  and  yet  there 
was  neither  ulcer  in  the  soft  parts  nor  caries  in  the  hard.  The 
two  tumours  were  scirrhous  and  no  appearance  of  polypus  was 
observed  in  the  nose. 

What  the  result  of  proper  surgical  treatment  would  have  been 
in  this  case,  had  the  seat  of  the  disease  been  known,  it  is  impos- 
sible to  conjecture,  since  not  a word  is  said  concerning  the  cau- 
ses, neither  local  nor  constitutional,  that  gave  rise  to  the  tumour. 
There  is  nothing,  therefore,  in  the  history  of  the  case,  of  special 
interest  to  the  practitioner,  and  I have  given  place  to  it  here  only 
for  the  purpose  of  showing  the  importance  of  ascertaining  the 
seat  of  morbid  productions  which  develop  themselves  in  the  nose. 
It  ismot  at  all  improbable  that,  had  it  been  known  in  the  case  just 
described,  a more  successful  plan  of  treatment  might  have  been 
instituted,  and  the  life  of  the  patient  saved. 

Case  XXVI. — A young  lady  of  Picardy  having  been  exposed 
to  the  changes  of  weather  for  three  years,  in  attending  to  business 
which  required  of  her  to  be  much  on  horseback,  experienced,  at 
the  end  of  the  first  year,  a chilly  sensation  in  her  left  cheek ; this 
increased,  and  her  cheek  became  swollen,  and  her  molar  teeth  of 
the  affected  side  loosened  and  two  dropped  out. 

The  swelling  of  her  cheek  increased,  and  she  was  affected  with 
lancinating  pains  in  that  side  of  her  face;  her  breath  became 
offensive  and  she  lost  two  more  teeth.  Becoming  alarmed,  she 

{ 


AND  PERIOSTEUM. 


133 


went  to  Rouen  to  obtain  medical  advice,  but  receiving  no  satis- 
faction, she  afterwards  went  to  Paris,  and  applied,  November 
20th,  1740,  to  M.  Croissant  de  Garengeot,  who  found  her  face 
greatly  disfigured.  Her  mouth,  he  says,  was  on  the  right  side, 
the  left  side  of  her  nose  much  elevated,  the  left  cheek  very  large, 
and  the  upper  lip  of  the  same  side  greatly  thickened.  Bluish  flesh 
of  the  size  of  an  olive  occupied  the  alveoli  of  the  teeth  which  had 
dropped  out,  the  left  side  of  the  roof  of  the  palate  was  thrown  in- 
wards and  resembled  the  exterior  projection  of  the  cheek.  The 
anterior  wall  of  the  antrum  had  become  softened  as  well  also  as 
that  of  the  left  nasal  bone,  and  the  whole  cavity  was  filled  with 
fungous  flesh. 

M.  Garengeot  commenced  the  operation  by  seizing  the  bluish 
excrescence  which  had  appeared  through  the  alveoli  with  a hook 
and  cutting  it  away ; and  he  says  he  incised  transversely,  every 
day,  from  within  the  mouth,  the  buccinator  muscle,  and  brought 
away  part  of  it  as  well  as  the  flesh  which  so  much  augmented 
the  size  of  the  jaw. 

The  hemorrhage  was  so  abundant  that  it  was  impossible  to 
proceed  further  with  the  operation.  The  excrescence  was  rap- 
idly reproduced  after  each  operation;  these  excisions  were  re- 
peated seven  or  eight  times  in  six  weeks,  and  the  hemorrhage, 
each  time,  was  very  great.  The  seat  of  the  disease  was  in  the 
anterior  of  the  sinus.  The  fungous  flesh  contained  in  this  cavity 
was  removed,  as  well  also  as  some  osseous  projections. 

The  excrescence  continuing  to  be  reproduced,  the  consent  of 
the  patient,  who  had  until  now  refused  to  have  the  actual  cautery 
applied,  having  been  obtained,  its  use  was  resorted  to,  twice  a 
day,  for  eight  days.  The  success,  says  M.  Garengeot,  which 


134  OP  TUMOURS  OP  ITS  LINING  MEMBRANE 

followed  this  treatment  was  incredible.  The  flesh  soon  took  on  a 
healthy  consistency,  the  palatine  arch  returned  about  two-thirds 
to  its  natural  situation,  and  the  bad  odour  of  the  mouth  gradually 
disappeared. 

The  application  of  the  cautery  was  continued,  once  a day,  for 
three  weeks,  and  the  patient  did  nothing  more  than  to  use  a 
slightly  stimulating  and  astringent  gargle.  On  the  20th  of  March 
she  returned  home  cured. 

It  is  very  probable  that  had  the  operation  in  the  case  just  de- 
scribed been  thorough,  there  would  have  been  no  return  of  the 
disease,  for  it  is  evident  from  the  description  which  M.  Garengeot 
gives  of  the  operation,  that  the  seat  of  the  affection  was  not 
reached  until  it  had  been  repeated  seven  or  eight  times;  and  then, 
I think  it  very  likely,  not  until  he  had  recourse  to  the  actual 
cautery. 

The  utility  of  the  actual  cautery,  not  only  for  the  purpose  of 
thoroughly  destroying  every  remaining  vestige  of  fungous  tu- 
mours of  the  antrum  maxillare  after  their  removal,  but  also  for 
the  suppression  of  hemorrhage,  would  seem  to  be  fully  established 
by  the  result  of  the  treatment  of  cases  twenty-four  and  six.  That 
there  are  cases  where  it  will  fail  to  prevent  their  reproduction 
there  is  no  question,  but  this  does  not  detract  from  its  value. 

The  employment  of  arsenical  preparations  has,  in  some  in- 
stances, been  found  highly  advantageous  in  repressing  the  growth 
of  fungous  excrescences.  The  following  case  is  cited  by  Mr. 
Thomas  Bell  as  an  example.* 

Case  XXVII. — “James  Woodly  was  admitted  into  Guy’s  Hos- 
pital, September  4th,  1821,  for  a fungous  exostosis,  which  arose 

# Anat.  Pliys.  and  Diseases  of  the  Teeth,  p.  283. 


AND  PERIOSTEUM. 


135 


from  the  antrum  maxillare,  and  made  its  way  through  the  palate. 
After  his  admission  he  had  the  fungus  removed  two  or  three 
times,  and  a variety  of  caustic  applications  were  afterwards  made 
use  of;  notwithstanding  which  the  tumour  reappeared.  At  length 
Sir  A.  Cooper,  after  having  made  an  incision  from  the  corner  of 
the  mouth  outwards  through  the  cheek,  removed  the  tumour  from 
a greater  depth  than  had  previously  been  effected.  After  this 
operation  the  wound  in  the  cheek  readily  healed,  and  the  follow- 
ing strong  solution  of  arsenie  was  daily  applied  to  the  part  from 
whence  the  tumour  had  been  removed. 

R.  Arsenic,  oxyd.  alb.  3 vi. 

Potass.  Subcarb.  q.  s. 

• Aq.  Distillat.  M.  ft.  solutio. 

The  solution  required  to  be  diluted  in  the  first  instance  on 
account  of  its  occasioning  him  a good  deal  of  pain,  in  a few 
days,  however,  he  used  it  of  the  strength  mentioned  in  the  for- 
mula. It  was  applied  regularly  every  afternoon,  after  which  he 
did  not  take  any  food  until  the  following  day.  At  the  time  of  its 
application  he  had  a piece  of  oiled  silk,  of  a horse-shoe  shape, 
passed  into  the  mouth,  its  sides  being  turned  up  to  prevent  the 
solution  escaping  into  the  mouth:  his  head  then  hanging  down 
over  a basin,  a piece  of  sponge  moderately  saturated  with  the 
solution  was  applied  to  the  disease  upon  the  oiled  silk,  pressed 
against  the  part ; such  of  the  solution  as  was  then  pressed  out, 
passed  along  the  channel  of  the  oiled  silk  into  the  basin  over 
which  the  head  was  hanging,  and  the  saliva  escaped  behind  the 
oiled  silk  into  the  same  utensil.  He  kept  the  sponge  in  this  situa- 
tion until  it  gave  him  considerable  pain,  when  it  was  removed 
and  the  mouth  carefully  washed.  He  suffered  great  pain  in  his 


136 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE 


mouth  during  the  period  of  the  cure;  but  the  arsenic  did  not 
produce  any  other  unpleasant  symptoms.  This  application  was 
continued  for  a few  weeks,  at  the  end  of  which  time  he  was 
completely  cured ; a cavity  being  left  in  the  site  of  the  tumour, 
which  however,  gradually  became  covered  by  a continuation  of 
the  membrane  which  naturally  lines  the  palate.” 

There  are  a number  of  highly  interesting  cases  of  sarcomatous, 
carcinamatous,  and  other  kinds  of  tumours  of  the  maxillary  sinus, 
in  Jourdain’s  Treatise  on  the  Surgical  Diseases  of  the  Mouth ; 
some  of  which,  I had  intended  to  introduce  into  this  treatise,  but 
apprehending  that  it  would  extend  it  to  too  great  a length  were  I 
to  do  so,  I have  concluded  to  omit  their  insertion.  A number  of 
other  equally  interesting  cases  reported  in  various  other  works,* 
are  for  the  same  reason  excluded. 

But  before  dismissing  this  branch  of  the  subject,  I will  add  the 
history  of  one  more  case  of  tumour  of  this  cavity,  taken  from  the 
“Boston  Medical  and  Surgical  Journal,”  the  treatment  of  which, 
involved  the  removal  of  the  superior  maxillary  bone,  given  by 
that  justly  distinguished  and  eminent  surgeon,  J.  C.  Warren, 
M.  D.  of  Boston,  and  although  it  is  of  considerable  length,  the 
method  of  procedure  is  so  minutely  detailed,  that  it  furnishes  a 
more  correct  description  of  the  operation,  than  any  which  could 
otherwise  be  given. 

Case  XXVIII. — “The  patient,  Mr.  J.  G.”  says  Dr.  Warren, 
“is  35  years  old,  well  constituted,  and  in  every  particular  strong 

* Vide  Journal  de  Chirurgie,  tom.  1 ; Parissian  Chirurgical  Journal,  tom. 
1.;  (Euvres  Chir.  de  Desault,  par  Bichat,  tom.  2.;  New  London  Med.  Jour, 
vol.  1.;  Eichorn.  Diss.  de  Polypis  in  Antro.  Highmori.  Trans,  of  a Society 
for  the  Improvement  of  Med.  and  Chir.  Knowledge.  Recueil  Periodique  de 
la  Soc.  de  Med.  tom.  2.;  No.  9.  Edinburg  Med.  and  Chir.  Jour.  Nos.  S3  and 
84;  Traite  des  Maladies  Chirurgicales,  tom.  6.;  Traite  des  Maladies  des 
Fosses  Nazales,  New  York  Jour,  of  Med.  and  Surgery,  Western  Lancet. 
Cooper’s  Surgical  Dictionary,  Benj.  Bell’s  Surgery,  vol.  4,  &.c.  Sec. 


AND  PERIOSTEUM. 


137 


and  healthful,  with  the  exception  of  the  disease  which  called  for 
this  operation.  About  nine  months  since  he  began  to  be  affected 
with  frequent  and  considerable  bleedings  from  the  nose.  These 
bleedings  occurred  t about  once  a week,  and  were  sometimes 
profuse.  During  the  occurrence  of  one  of  these  attacks,  he  was 
led  to  pass  the  finger  deep  into  the  left  nostril,  and  discovered 
there  a tumour  about  the  size  of  a pea,  in  the  outer  side  or  wall 
of  the  cavity. 

The  bleedings  continued  and  the  tumour  grew,  till  it  made  a 
visible  appearance  in  the  aperture  of  the  left  nostril.  Alarmed  at 
this,  he  consulted  Dr.  Winslow  Lewis,  who,  suspecting  a formi- 
dable disease,  advised  him  to  apply  at  the  Massachusetts  General 
Hospital  for  advice  and  assistance.  He  was  there  examined  by 
Dr.  Hayward  and  myself,  and  presented  the  following  appear- 
ances. The  left  nostril  was  filled  by  a tumour  of  a deep  red 
colour  and  soft  consistence,  discharging  blood  freely  on  being 
subject  to  a slight  touch.  A probe  could  be  introduced  into  the 
cavity  on  the  inner  side  of  the  tumour  along  the  septum  of  the 
nose;  but,  on  the  outer  wall,  -was  soon  arrested  in  its  progress  by 
the  tumour,  which  appeared  to  be  connected  with  this  part,  and 
bled  so  copiously  as  to  prevent  a continuance  of  the  examination 
in  this  direction.  The  external  appearance  of  the  face  being 
examined,  the  nose  was  seen  to  be  tumefied  on  the  left  side  by  the 
protrusion  of  the  nasal  process  of  the  upper  jaw,  and  also  by  that 
part  of  the  bone  forming  the  exterior  wall  of  the  nasal  cavity. 
On  opening  the  mouth,  the  hard  palate  was  seen  to  be  the  seat  of 
a tumour  of  an  elastic  character,  oval  form,  and  size  sufficient  to 
occupy  a considerable  portion  of  this  cavity,  obviously  produced 
by  the  pressure  of  a substance  in  the  nostril  above.  The  mucous 

membrane  of  the  mouth  was  not  altered  in  colour  or  consistence, 

17 


138 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE 


On  passing  the  finger  through  the  mouth  into  the  posterior 
opening  of  the  nostril,  this  aperture  was  found  to  be  filled  by  a 
soft  elastic  tumour,  similar  to  that  which  occupied  the  anterior 
apertui’e.  The  septum  of  the  nose  was  slightly  inclined  into  the 
right  nostril. 

Such  were  the  history  and  appearances  of  this  tumour.  Its 
vivid  red  colour,  soft  consistence,  disposition  to  bleed,  rapid 
growth,  and  consequent  breaking  down  of  the  bones  which  sur- 
rounded it,  satisfied  me  that  it  was  a cephaloma,  a malignant 
fungus,  which  would  destroy  the  patient’s  life  in  a short  time 
unless  extirpated:  and  I,  therefore,  advised  him  to  enter  the 
hospital,  and  have  it  removed.  The  patient  agreed  to  this  course, 
and  went  home  to  make  his  arrangements. 

In  nine  days  after,  he  entered.  When  I came  to  examine  the 
tumour  again,  I found  that,  during  this  short  period,  it  had  en- 
larged considerably;  and  especially  that  it  had  extended  to  the 
right  side  of  the  palate  so  far  as  to  leave  a small  space  only 
between  it  and  the  teeth  of  that  side.  I was  now  seriously  appre- 
hensive that  no  operation  could  wholly  eradicate  the  tumour,  and 
felt  much  doubt  whether  it  would  be  expedient  to  attempt  one,  in 
itself  always  severe,  and  which  in  this  case  would  he  attended 
with  dangerous  bleeding.  After  weighing  the  arguments  on  both 
sides  for  three  or  four  days,  I came  to  an  affirmative  conclusion, 
provided  other  gentlemen  were  of  the  same  opinion.  On  the 
Saturday  following,  the  4th  of  December,  a consultation  was 
held,  consisting  of  Drs.  Hayward,  Townsend,  and  Holmes,  and 
these  gentlemen  being  satisfied  that  as  there  was  no  other  ground 
of  hope  for  the  patient,  and  that  he  must  die  in  a most  distressing 
manner,  the  operation  was  decided  on,  and  immediately  after 
executed. 


AND  PERIOSTEUM. 


139 


The  principal  difficulties  I anticipated  in  this  operation  were 
the  following : — 1.  Profuse  bleeding,  which  the  character  of  the 
tumour,  the  tendency  of  blood  to  the  head  produced  by  it,  and 
the  fulness  of  the  patient’s  habit,  seemed  to  promise.  2.  Imprac- 
ticability of  dividing  the  bones  without  sawing,  as  the  patient  was 
of  an  aspect  which  indicated  unusual  solidity  of  the  osseous 
texture.  3.  Fatal  syncope,  from  the  quantity  of  blood  lost  and 
the  pain  of  the  operation. 

To  obviate  these  dangers  I proposed — 1.  Compression  of  the 
carotid  arteries,  tying  of  the  wounded  vessels  when  they  bleed 
freely,  and  the  use  of  the  actual  cautery.  2.  Division  of  the  bones 
by  the  cutting  forceps,  which  I had  caused  to  be  made  and  used 
for  the  last  twenty  years.  3.  Waiting  occasionally  to  give  the 
patient  time  to  recover,  and  recruiting  him  with  cordials. 

Every  thing  being  arranged,  the  patient  was  placed  in  a chair, 
his  head  well  supported,  and  the  operation  was  then  begun  in 
presence  of  the  medical  class  and  a considerable  number  of  medi- 
cal gentlemen  of  the  city. 

I made  an  incision  from  the  middle  of  the  external  edge  of  the 
left  orbit  to  the  left  angle  of  the  mouth,  down  to  the  bone.  A 
most  copious  gush  of  blood  succeeded.  The  internal  flap  was 
then  quickly  dissected  up  to  the  middle  of  the  nose,  cutting  up  at 
the  same  time  the  cartilage  of  the  left  wing  of  the  nose,  and  free- 
ing the  globe  of  the  eye  from  the  inferior  part  of  the  socket  by 
the  division  of  the  inferior  oblique  muscle,  the  fascia  of  the  eye, 
and  the  periosteum.  The  outer  flap  was  then  rapidly  dissected 
from  the  os  malse  and  os  maxillas,  and  around  the  latter  bone  as 
far  as  its  union  with  the  pterygoid  process  of  the  sphenoid  ; bu‘ 
the  uniting  space  was  not  at  this  time  penetrated  on  account  of 


140  OP  TUMOURS  OF  ITS  LINING  MEMBRANE 

the  large  pterygoid  branch  of  the  internal  maxillary,  which  would 
have  been  difficult  to  secure  in  this  stage  of  the  operation. 

The  two  flaps  being  separated,  the  anterior  extremity  of  the 
spheno-maxillary  fissure  was  perforated,  and  I then  proceeded  to 
the  division  of  the  bones.  The  os  malse  was  attached  directly 
opposite  to  the  perforation  in  the  spheno-maxillary  fissure.  The 
cutting  forceps  were  then  applied  to  the  broadest  part  of  the  malar 
bone,  and  divided  it  smoothly  in  a few  seconds.  Second,  the 
same  instrument  was  applied  at  the  internal  angle  of  the  eye,  in 
an  oblique  direction  from  the  lower  edge  of  the  orbit  to  the  lower 
termination  of  the  os  nasi.  Here  the  projection  of  the  tumour  into 
the  orbit  occasioned  some  dfficulty,  from  the  little  space  left  for 
its  introduction  into  the  orbit;  but,  the  instrument  being  fixed, 
the  bone  was  divided  without  difficulty. 

In  the  meantime,  the  blood  continued  to  flow  in  torrents.  One 
considerable  artery  required  immediate  ligature  : and  the  bleeding 
of  the  others  was  controlled  by  compression  of  the  carotid  artery. 
The  mouth  of  the  patient  filling  with  blood,  frequent  pauses  were 
required  to  afford  him  an  opportunity  of  ejecting  it,  and  occasion- 
ally he  was  recruited  by  a little  wine. 

The  most  difficult  part  of  the  operation  remained ; that  of 
dividing  the  sound  from  the  unsound  parts  within  the  mouth,  and 
separating  the  maxillary  from  the  sphenoid  and  palatine  bones 
without  injury  to  the  latter ; so  as  to  leave  the  patient  the  whole 
of  the  soft  palate,  with  the  palatine  plate  of  the  os  palati  to  support 
it.  In  order  to  accomplish  this  without  dissection,  I made  an 
incision  through  the  mucous  membrane  of  the  hard  palate,  begin- 
ning at  the  edge  of  the  palatine  plate  of  the  os  palati,  and  extend- 
ing the  incision  forwards  to  the  external  edge  of  the  jaw,  then 


AND  PERIOSTEUM. 


Ill 


upwards  across  the  alveoli  into  the  bone.  To  facilitate  this 
incision,  the  middle  incisor  tooth  of  the  left  side  was  taken  out  in 
such  a way  as  to  break  the  anterior  part  of  the  alveolus.  Then 
by  a single  stroke  of  the  cutting  forceps  the  upper  maxillary  bone 
was  divided,  and  its  palatine  plate  cut  through  as  far  as  its 
junction  with  the  os  palati.  In  order  to  separate  the  palatine 
plates  of  the  maxillary  and  palatine  bones,  I hoped  to  be  able  to 
clear  the  mouth  of  blood  for  a moment  to  make  a transverse  out 
between  these  plates.  But  to  see  was  impossible,  from  the  flow 
of  blood.  Therefore,  passing  the  fore-finger  of  the  left  hand  into 
the  mouth,  I felt  the  last  molar  tooth,  and  turning  the  pulp  of  the 
finger  forwards  to  receive  and  support  the  instrument,  I struck  a 
strong-pointed  knife  through  the  hard  palate  at  the  union  of  the 
maxillary  and  palate  bones,  separated  these  bones,  and  was  able 
also  to  separate  the  maxillary  bone  from  the  pterygoid  process  of 
the  sphenoid,  and  thus  accomplished  the  disunion  of  all  the  bones 
concerned.  Finally,  the  knife  was  passed  externally  behind  the 
upper  maxillary  bone  into  the  space  between  this  and  the  pterygoid 
process,  to  divide  the  second  branch  of  the  fifth  pair  of  nerves. 
This  was  done  by  a stroke  of  the  instrument,  and  the  patient 
made  a great  cry,  evincing  that  this  nerve  had  been  reached. 

Seizing  the  bone  with  the  left  hand  by  its  orbitar  and  alveolar 
portions,  it  was  by  a gradual  movement  started  from  its  situation, 
and  aided  by  a few  touches  of  the  knife,  its  remaining  periosteal 
attachments  were  divided,  and  the  whole  bone  and  tumour  dis- 
lodged from  the  face. 

The  patient  having  lost  much  blood,  had  now  become  faint, 
and  was,  therefore,  placed  on  a table.  The  portion  of  swelled 
mucous  membrane  on  the  right  side  of  the  palate  was  cut  off  with 


142 


OP  TUMOURS  OF  ITS  LINING  MEMBRANE 


ease,  and  it  now  only  remained  to  arrest  the  hemorrhage.  A 
ligature  was  applied  to  the  superior  ethmoidal  branch  or  conti- 
nuation of  the  maxillary  artery.  The  hemorrhage  from  a second 
artery  also  required  to  be  arrested.  This  was  not  easily  done,  for 
it  was  impossible  to  discover  the  orifice  of  the  wounded  vessel. 
It  was,  therefore,  touched  with  caustic  potass,  and  lint  applied  to 
it.  As  the  bleeding  might  recur,  the  wound  was  not  immediately 
brought  together,  but  was  covered  with  a cold-water  compress, 
and  the  patient  left  in  the  operating  theatre.  He  was  able  to 
swallow  and  speak,  notwithstanding  his  exhaustion  and  the  length 
of  the  operation. 

The  time  expended  during  the  operation  I do  not  know,  having 
always  considered  it  the  part  of  folly  to  measure  an  operation  by 
time,  rather  than  the  exigencies  of  the  case.  I was  informed, 
afterwards,  it  was  over  forty  minutes.  The  principal  part  of  this 
time  was  expended  in  waiting  for  the  patient  to  relieve  his  mouth 
and  throat  of  blood,  which  appeared  to  embarrass  him  more  than 
I had  expected.  But  the  time  employed  in  the  incisions,  both  of 
the  soft  and  hard  parts,  was  short,  and  certainly  could  not  have 
exceeded  ten  minutes. 

In  three  hours  after  the  operation,  no  bleeding  having  occurred, 
the  wound  was  dressed  by  passing  five  sutures  and  applying  a 
cloth  of  four  thicknesses  wet  in  cold  water,  to  be  moistened  from 
time  to  time ; and  then  he  was  carried  to  his  bed.  He  passed 
the  night  rather  uneasily ; but  the  next  day  he  was  more  quiet. 
The  pulse,  for  four  or  five  days  after  the  operation,  varied  from 
80  to  112;  at  the  end  of  six  days  it  was  72.  The  third,  day,  the 
wound  being  wholly  united,  the  stitches  were  withdrawn  by  Mr. 
Hayward,  the  house-surgeon,  at  my  request.  In  two  or  three 


AND  PERIOSTEUM. 


143 


days,  the  patient  was  able  to  take  softened  bread ; and,  in  three 
weeks  from  the  operation,  went  home  to  pass  the  Christmas  with 
his  family — in  two  days  after  which,  he  was  discharged.  At  the 
present  time,  eight  weeks  after  the  operation,  he  is  at  home,  takes 
food  freely,  and  speaks  intelligibly.  The  left  eye,  at  first  much 
swelled,  is  in  a natural  state,  and  he  uses  it  without  uneasiness. 
On  the  left  side  of  the  palate  there  is  an  aperture  of  a triangular 
form.  Through  this,  the  os  ethmoides  may  be  felt,  the  projections 
of  which  were  mistaken  by  the  patient  for  a return  of  his  disease. 
The  food  occasionally  passes  through  this  aperture  into  the  nostrils, 
and  embarrasses  the  patient  momentarily.  The  soft  palate  is 
entire.  There  is  a slight  paralysis  of  the  left  side  of  the  upper 
lip,  from  the  division  of  the  facial  nerve;  and  a want  of  sensibility 
in  the  left  side  of  the  nose  and  the  left  upper  lip,  from  the  division 
of  the  second  branch  of  the  fifth  pair  of  nerves. 

Description  of  the  Tumour. — The  tumour,  after  its  removal, 
exhibited  the  following  appearances.  At  its  summit  appeared  the 
lower  floor  of  the  orbit  of  the  eye,  at  the  inside  of  which  was  a 
portion  of  the  nasal  process  of  the  os  maxillary  superius.  On  its 
outer  part  projected  one  half  of  the  os  malse;  below  appeared  the 
left  half  of  the  palate,  with  the  exception  of  the  part  which 
belongs  to  the  palatine  plate  of  the  os  palati.  A portion  of  the 
fossa  canina,  and  the  whole  alveolar  margin,  with  the  correspondent 
teeth,  were  visible.  On  the  inner  wall  of  the  mass  appeared  three 
considerable  red-coloured  lobes,  attached  to  the  outer  and  inferior 
part  of  the  maxillary  cavity,  by  something  like  a pedicle,  about 
an  inch  in  diameter — the  three  lobes  being  connected  at  their 
attachment,  but  separated  at  their  internal  or  nasal  extremity  into 
an  anterior,  middle,-  and  posterior  lobe.  The  superior  maxillary 


144 


OP  TUMOURS  OF  ITS  LINING  MEMBRANE 


nerve  was  seen  in  and  behind  the  orbit.  The  whole  was  covered 
by  membranes  which  separated  it  from  the  parts  in  contact.  One 
lobe  had  made  its  way  through  the  bone  of  the  face ; the  others 
through  the  partition  between  the  nostril  and  antrum.” 

Having  now  quoted  the  description  of  the  operation  and 
tumour,  I shall  notice  but  a few  of  the  remarks  that  follow. 
“The  texture  of  the  tumour,”  says  Dr.  Warren,  “was  in  con- 
sistence somewhat  spongy  and  elastic,  and  was  very  vascular.” 
Again  he  observes:  “In  order  to  judge  of  the  propriety  of  operat- 
ing in  such  cases,  we  must  distinguish  from  each  other  the 
different  tumours  which  begin  in  the  maxillary  cavity  and  extend 
into  the  nostril,  and  raise  the  bony  parietes  of  the  face,  orbit,  and 
palate.  I have  seen  four  different  species  of  such  tumour.  First, 
the  osteo-sarcoma,  of  the  upper  maxillary  bone;  second,  the 
fibrous  tumour;  third,  scirrhoma;  and  fourth,  cephaloma.” 

“The  first,  osteo-sarcoma,  is  the  most  formidable  in  appearance, 
and  attains  the  greatest  size.  Its  growth  is  rapid  and  luxuriant ; 
it  breaks  down  the  surrounding  bones,  and  produces  enormous 
deformity.  This  affection,  terrible  as  it  is  in  appearance,  is 
tractable  by  operation,  and  its  careful  removal  is  generally  follow- 
ed by  a successful  result.  The  second,  fibrous  tumour,  is  of 
slower  growth,  and  more  limited  in  its  ravages.  This  may  be 
removed  with  a reasonable  certainty  of  its  not  returning.  Third, 
scirrhoma.  This  form  of  tumour  of  the  antrum  is  characterized 
by  its  hardness,  the  pains  which  attend  it,  its  moderate  growth 
and  certain  fatality.  Fourth,  the  cephalomatous  is  rapid  in  its 
growth,  and  of  a spongy  texture,  produces  excessive  bleedings, 
and  terminates  by  death  unless  removed  at  an  early  stage.” 

It  was  for  the  removal  of  this  fourth  species  of  tumour  that  Dr. 


AND  PERIOSTEUM. 


145 


Warren  operated,  and  although  more  than  a year  has  elapsed 
since  the-  operation  was  performed,  there  are  no  indications,  so 
far  as  I have  been  able  to  learn,  of  a return  of  the  disease. 

In  remarking  upon  the  causes  of  malignant  tumours,  Dr.  W. 
argues  that  those  who  hold  that  such  morbid  production,  “are 
necessarily  and  early  the  result  of  a contaminated  circulating 
fluid,”  “must  of  course  believe  that  every  operation  for  their  re- 
moval,” “is  utterly  unavailing,”  and,  while  he  admits  “that  a great 
number”  “are  followed  by  signs  of  a general  vitiation  of  the 
blood,”  he  believes  that  inasmuch  as  they  are  not  always  repro- 
duced after  their  extirpation,  that  they  often  attack  persons  who 
are  unaffected  with  any  general  or  constitutional  vice  whatever. 

I fully  concur  in  the  opinion,  that,  if  all  malignant  tumours 
resulted  from  a vitiation  of  the  circulating  fluid,  independently  of 
all  other  causes,  no  operation  for  their  removal  would  be  success- 
ful, but  I cannot  admit  that,  inasmuch  as  they  are  sometimes 
successful,  it  follows,  that  individuals  unaffected  with  any  consti- 
tutional taint  or  vice,  may,  and  not  unfrequently  do,  become  the 
subjects  of  them.  I do  not  think  that  this  conclusion  is  warranted 
by  the  premiss,  but  having  already  endeavoured  to  show,  that 
local  causes'  alone,  are  incapable  of  producing  them,  and  that 
they  were  dependent,  both  upon  these,  and  some  constitutional 
vice  or  taint,  it  will  not  be  necessary  to  repeat  what  has  before 
been  said  upon  the  subject. 

In  conclusion,  I would  remark,  that  Professor  Pattison  proposed 
in  1820,  for  the  dispersion  of  fungous  tumours  of  the  maxillary 
sinus,  the  tying  of  the  carotid  artery.  He  was  induced  to  recom- 
mend this  method  of  treatment,  from  the  consideration,  that  the 

“capability  of  action  of  a part,  is  proportioned  to  its  vascularity,” 
18 


146 


OF  TUMOURS  OF  ITS  LINING  MEMBRANE. 


and  that  thus  by  cutting  off  the  circulation  of  blood  to  it,  the 
morbid  growth  would  slough  and  be  thrown  off.  He  says  this 
practice  has  been  successful  where  it  has  been  adopted,  in  all  the 
cases  that  have  come  to  his  knowledge.* 

* Vide  Appendix  to  Surgical  Anatomy  of  the  Head  and  Neck,  pages  477-8. 


CHAPTER  VIII. 


f'VWNA/VWWN^ 


OF  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 

The  osseous  walls  of  the  maxillary  sinus  sometimes  become 
the  seat  of  bony  tumours — a disease  designated  by  medical  wri- 
ters by  the  name  of  exostosis.  This,  however,  is  not  an  affection 
peculiar  to  the  bony  parietes  of  this  cavity;  all  of  the  osseous 
structures  of  the  body  are  liable  to  be  attacked  by  it. 

Exostoses,  like  many  other  diseases,  presents  several  varieties. 
It  is  divided  by  some  writers  into  true  and  false,  the  one  consist- 
ing of  a tumour  composed  wholly  of  bone,  or  nearly  so,  and  the 
other,  of  a tumour  composed  both  of  ossific  matter  and  fungous 
flesh,  or  of  a mere  thickening  of  the  periosteal  tissue.*  Sir  Astley 
Cooper  divides  exostoses  into  periostea],  medullary,  cartilaginous 
and  fungous.  The  first  consists  of  a deposition  of  bony  matter 
on  “the  external  surface  of  a bone  and  the  internal  surface  of  its 
periosteum,”  and  to  both  of  which  it  firmly  adheres.  The  second 
consists  of  “a  similar  formation,  originating  in  the  medullary  mem- 
brane and  cancellated  structure  of  the  bone this  description  of 
exostosis  never  attacks  the  walls  of  the  maxillary  sinus.  By  car- 
tilaginous exostosis  he  means  that  which  is  preceded  by  the  for- 
nhation  of  cartilage,  which  forms  the  nidus  for  the  ossific  deposite.” 

* Vide  Dietionnaire  des  Sciences  Medicales,  t.  xiv.  p.  218. 


148 


OP  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 


Fungous  exostosis  he  describes  to  be  a tumour  not  so  firm  in  its 
consistence  as  cartilage,  but  harder  than  fungous  flesh,  having  in- 
terspersed through  its  substance  spicula  of  bone,  of  a malignant 
character,  and  dependent  upon  some  peculiar  constitutional  dia- 
thesis, and  action  of  vessels  # This  species  of  exostosis  differs 
but  little,  if  at  all,  from  osteo-sarcoma. 

Exostoses  differ  as  much  in  shape  as  they  do  in  structure. 
They  sometimes  rise  abruptly  from  the  surfaces  of  hones  by  a 
narrow  and  circumscribed  base,  projecting  in  large  irregularly  or 
spherically  shaped  masses ; at  other  times  they  rise  very  gradually, 
covering  a larger  surface  of  the  affected  bone,  but  less  massy  and 
with  limits  less  perfectly  defined.  An  exostosis  has  been  known 
to  occupy  the  whole  extent  of  the  surface  of  a bone.  “The  whole 
external  surface  of  one  of  the  bones  of  the  skull  was  found  occu- 
pied by  an  exostosis,  while  the  cerebral  surface  of  the  same 
bone  was  in  a natural  state. ”f  Both  sides  and  the  whole  thick- 
ness of  bones  are  occasionally  affected  by  this  disease.  But  this 
is  what  Sir  Astley  Cooper  calls  periosteal  exostosis. 

This  disease  is  said  to  attack  some  bones  more  frequently  than 
others.  Those  of  the  skull,  the  lower  jaw,  sternum,  humerus, 
radius,  ulna,  femur,  tibia  and  bones  of  the  carpus  are  said  to  be 
the  most  subject  to  it.j  It  also,  very  frequently  attacks  the  upper 
jaw,  and  none  of  the  bones  of  the  body,  in  fact,  are  exempt  from  it. 

The  texture  of  exostoses  is  sometimes  spongy  and  cellular,  at 
other  times  it  is  very  dense.  Dr.  E.  Carmichael,  a distinguished 
surgeon  and  physician,  formerly  of  Fredericksburg,  but  now  of 

* Surgical  Essays,  part  1,  page  155. 

t Vide  last  American  edition  of  Cooper’s  Surgical  Dictionary,  p.  362. 

J Vide  last  Am.  ed.  of  Cooper’s  Surgical  Dictionary,  p.  362. 


OF  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 


149 


Richmond,  Va.,  described  to  me,  about  four  years  since,  an  exos- 
tosis of  the  superior  maxillary,  which  had,  a short  time  before, 
fallen  under  his  observation,  larger  than  a hen’s  egg,  and  as  solid 
as  ivory.  Exostoses  of  the  roots  of  the  teeth  are  always  hard, 
exceeding  in  density,  very  frequently,  even  tooth-bone;  and 
instances  are  sometimes  met  with  of  osseous  tumours  upon  other 
bones  possessed  of  nearly  an  equal  degree  of  solidity.  Exostoses 
of  this  description  grow  less  rapidly  than  those  which  are  more 
cellular;  but  they  notwithstanding  sometimes  acquire  a very  large 
size:  it  is  not,  however,  uncommon  for  such,  after  having  attain- 
ed a greater  or  less  size,  to  cease  to  grow,  and  “remain  station- 
ary” through  life,  without  giving  rise  to  any  very  serious  or  un- 
pleasant consequences.* 

Exostoses  sometimes  attain  an  enormous  size,  and  especially 
upon  cylindrical  bones ; very  large  ones  too,  are  frequently  met 
with  upon  the  maxillse.  The  largest  one  however,  I believe,  of  the 
maxillary  sinus,  of  which  medical  history  furnishes  any  account, 
is  exhibited  upon  a specimen  of  morbid  anatomy,  presented  in 
1767,  by  M.  Beaupreau,  to  the  French  Academy.  A description 
and  drawing  of  this  tumour  is  contained  in  the  Memoirs  of  the 
Royal  Academy  of  Surgery,  but  we  have  no  account  of  the 
history  of  its  formation,  nor  of  the  symptoms  that  resulted  from 
it.  The  tumour  occupies  the  whole  of  the  right  maxillary  sinus, 
and  several  of  the  neighbouring  bones  are  involved  in  it.  It  is 
very  large  near  its  base  and  projects  from  the  lower  part  of  the 
orbit,  forward  and  downward,  six  inches.  Its  largest  circum- 
ference, is  said  to  be  one  foot.  The  upper  part  of  the  maxillary 
bone,  says  Bordenave,  projects  on  the  side  of  the  orbit,  and 

# Vide  Cooper’s  Surgical  Dictionary,  p.  363. 


150 


OF  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 


straightens  the  cavity;  the  os  unguis  is  included  in  the  mass  of 
the  tumour  and  is  represented  as  being  nearly  effaced.  The  nasal 
bones  of  the  left  side  are  displaced,  and  the  right  nostril  entirely 
closed  up,  and  the  exostosis  projects  so  much  on  the  left  side  os  to 
be  nearly  underneath  the  malar  bone.  The  inferior  part  of  the 
maxillary  bone,  says  our  author,  is  so  extended  near  its  base, 
that  it  inclines  obliquely  to  the  left,  and  the  pterygoid  apophyses  of 
this  side  are  larger  than  those  of  the  other.  The  malar  bone  is 
described  as  being  involved  in  the  upper  and  external  part  of  the 
exostosis,  which  extends  to  the  left  maxillary  bone. 

Exteriorly,  says  Bordenave,  the  tumour  had  a smooth  and 
polished  appearance,  its  upper  part  was  very  hard,  inferiorly  its 
substance  had  become  thinner,  was  wanting  in  some  places,  and 
the  interior  of  the  exostosis  was  exposed.  The  substance  of  the 
bone  here  was  spongy  and  serous,  and  in  appearance,  not  unlike 
pumice  stone.  The  walls  were  thick,  and  measured  in  some 
places  one  inch.* 

From  this  brief  description,  taken  from  the  one  given  of  it  by 
Bordenave,  some  idea  may  be  formed  of  the  dimensions  and 
appearance  of  this  enormous  and  most  remarkable  exostosis. 

A case  of  exostosis  of  each  antrum  is  described  by  Sir  Astley 
Cooper,  both  of  which,  forced  themselves  up  into  the  orbits,  and 
pushed  the  eyes  from  their  sockets.  One  made  its  way  into  the 
brain,  and  caused  the  death  of  the  patient. f 

Mr.  Thomas  Bell  does  not  believe  in  the  occurrence  of  “true 
exostosis  upon  the  bony  parietes”  of  this  cavity ,J  but  too  many 

# Vide  Memoires  de  l’Academie  Royale  deChirurgie,  t.  xiii.  obs.xii.  p.  412. 

f Surgical  Essays,  part  1.  p.  157. 

JVide  Anat.  Phys.  and  Diseases  of  the  Teeth,  p.  281. 


OF  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES.  151 

examples  have  presented  themselves,  to  leave  any  room  for  doubt 
upon  the  subject.  Although  none  may  never  have  fallen  under 
his  own  immediate  observation,  there  are  many  well  authenti- 
cated cases  on  record, — the  details  of  some  of  which,  I shall 
presently  give.  But  apart  from  these,  I think  it  would  be  difficult 
to  assign  any  sound  reasons  for  supposing  that  the  osseous  walls 
of  this  cavity  should  be  more  exempt  from  the  disease  than  the 
other  bones  of  the  body. 

Symptoms. — The  attacks  of  exostoses  of  the  walls  of  the  max- 
illary sinus,  are  generally  so  insiduous,  that  the  presence  of  the 
disease,  is  not  for  a long  time,  even  suspected.  Those  which 
result  from  venereal  vice,  Boyer  says,  are  preceded  by  acute  pain, 
extending  at  first  to  almost  every  part  of  the  affected  bone,  but 
which  afterwards  confines  itself  to  the  affected  portion.  Those 
which  are  occasioned  by  scrofula,  the  same  writer  tells  us,  are 
attended  by  a duller  and  less  severe  pain,  and  that  the  symptoms 
of  those  resulting  from  causes  purely  local,  such,  for  example,  as 
a blow,  are  very  similar.*  But  these  signs  are  common  to  the 
disease  wherever  it  may  be  situated,  and  when  it  is  seated  in  the 
maxillary  sinus,  they  do  not  distinguish  it  from  many  of  the  other 
affections  that  occur  here ; for  they  are  often  produced  by  them, 
as  well  as  by  exostoses.  And  furthermore,  the  disease,  not  un- 
frequently  gives  rise  to  other  symptoms  which  are  attendant  upon 
several  of  the  other  affections  of  this  cavity,  so  that  previously  to 
the  distension  of  its  walls  by  it,  it  may  be  confounded  with  inflam- 
mation of  the  lining  membrane,  or  sarcomatous  or  other  tumours. 
But  after  it  has  filled  the  sinus,  or  very  considerably  thickened  its 
exterior  walls,  it  will  cause  them  to  offer  a firmer  resistance  to 


* Traile  des  Maladies  Chirurgicales,  t,  iii,  p.  545, 


152  OF  EXOSTOSES  'OF  ITS  OSSEOUS  PARIE'lES. 

pressure,  than  will  any  of  the  other  diseases  of  this  cavity.  When 
therefore,  they  have  become  distended,  if  they  are  firm  and  un- 
yielding to  pressure,  the  presence  of  exostosis  may  be  inferred. 

Causes. — There  is  a difference  of  opinion  among  writers  on  the 
diseases  of  the  bones,  with  regard  to  the  causes  of  exostoses.  Cer- 
tain constitutional  diseases, such  as  “scrofula  and  lues  venerea,”  are 
thought  by  some  to  give  rise  to  the  affection.  That  the  last  of 
these  diseases  is  favourable  to  its  production,  is,  I believe,  admitted 
by  all ; but  Sir  Astley  Cooper  declares  that  no  evidence  has  yet 
been  adduced  to  prove  that  the  former  is  ever  concerned  in  its 
production.*  Others  impute  the  disease  to  local  irritation  produ- 
ced by  contusions,  fractures,  &c.  &c.  But  it  is  probably  de- 
pendent upon  both  local  and  constitutional  causes,  and  that  neither, 
independently  of  the  other,  is  capable  of  producing  it. 

Treatment. — A variety  of  plans  of  treatment  have  been  recom- 
mended for  this  disease,  and  Bordenave  assures  us  that  it  may  be 
cured,  if  suitable  remedies  are  applied  before  the  exostosis  has 
acquired  much  solidity.  Assuming  that  it  sometimes  results  from 
constitutional  causes,  he  directs  that  the  treatment  should  be 
commenced  by  the  employment  of  such  means  as  are  indicated 
by  the  nature  of  the  vice  with  which  the  patient  may  be  affected. 
If  a venereal  vice  be  present,  the  use  of  mercurial  medicines  are 
recommended.  The  author,  last  mentioned,  says  he  has  known 
it  to  be  successfully  treated  with  mercury . j Topical  applications, 
such  as  fomentations  and  cataplasms,  have  also  been  found  ser- 
viceable. Boyer  advises  poultices  of  linseed  meal,  and  a decoction 
of  the  “leaves  of  henbane  and  nightshade.”  Iodine  and  mercury 

♦Vide  last  American  edition  of  Cooper’s  Surgical  Dictionary',  p.  363. 

t Vide  Memoires  de  l’Academie  Royale  de  Chirurgie,  t.  xiii.  p.  403 


OP  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 


153 


have  been  employed,  but  not,  I believe,  with  any  decided  advan- 
tage. Sir  Astley  Cooper  thinks  the  best  internal  remedy  is  “oxy- 
muriate  of  quicksilver,  together  with  the  compound  decoction  of 
sarsaparilla.*  But  I believe,  with  Boyer,  that  a dispersion  of  an 
exostosis  can  never  be  effected. f Its  progress  may  perhaps  be 
partially  arrested,  but  I do  not  believe,  as  many  do,  that  it  is  ever 
removed  by  the  absorbents.  But  it  is  not  advisable  to  remove 
exostoses  unless  they  continue  to  augment  and  are  likely  to  be- 
come dangerous,  or  are  productive  of  serious  inconvenience. 

When,  therefore,  the  remedies  which  have  here  been  mentioned, 
after  having  been  thoroughly  tried,  prove  unsuccessful,  the  tumour 
should  be  fully  exposed;  firstly,  by  the  dissection  of  the  gum  and 
other  soft  parts  from  the  exterior  wall  of  the  sinus,  and  secondly, 
by  the  perforation  of  this  cavity  with  a trephine,  or  such  other  in- 
strument as  can  be  most  conveniently  employed.  This  part  of 
the  operation,  though  simple,  should  be  conducted  with  care,  but 
if  the  tumour  be  large  and  attached  by  a very  broad  base,  its 
removal  will  sometimes  prove  more  difficult,  yet  by  means  of 
suitably  constructed  saws,  scissors,  knives,  &c.,  it  may,  in  most 
instances,  be  easily  effected.  An  external  wound  through  the 
cheek  should  always,  if  possible,  be  avoided. 

The  method  of  operating,  however,  will  be  best  understood  by 
a description  of  that  pursued  in  the  two  following  cases.  The 
first  was  treated  by  Dr.  B.  A.  Rodrigues,  dentist,  of  Charleston, 
S.  C.,  and  reported  by  him  for  the  “American  Journal  of  Medical 
Sciences.” 

Case  XIXX. — “On  the  14th  of  August,  1837,  Charity,  a ser- 

* Vide  last  Am.  ed.  of  Cooper’s  Surgical  Dictionary,  p.  365. 
f -Traite  des  Maladies  Chirurgicales,  t,  iii.  pp.  554 — 557. 

19 


154 


OF  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 


vant  woman  of  Mrs.  Miller,  called  on  me  to  ascertain  whether  I 
could  afford  her  any  relief  in  her  wretched  condition.  She  had 
been  labouring  under  incessant  and  agonizing  pain  in  the  antrum 
highmorianum  of  the  right  side,  which  she  regarded  as  the  conse- 
quence of  the  impaired  condition  of  the  teeth.  On  this  supposition, 
she  had  several  of  them  extracted,  without  any  appreciable  abate- 
ment of  her  sufferings.  Yet  deluded  with  the  belief  that  some  one 
of  the  remaining  teeth  was  the  secret  agent  of  all  she  suffered, 
she  persisted  in  having^  more  extracted.  Still  the  evil  continued, 
the  suffering  was  unabated,  the  cause  undetected ; and  to  add  to 
the  depression  of  her  hopes,  and  the  aggravation  of  her  ills,  a 
purulent  discharge  oozed  from  the  empty  sockets  of  the  affected 
side.  She  again  had  recourse  to  medical  advice,  hoping  that  this 
phasis  of  her  malady  might  lead  to  some  indication  that  would 
relieve  her ; at  least,  that  it  might,  reveal  its  hidden  sources,  its 
condition,  and  its  prospects  of  being  remediable.  And  here  for 
the  first  time,  was  it  suggested  that  the  antrum  was  in  an  unsound 
state. 

It  was  at  this  moment,  under  these  circumstances,  that  she 
applied  to  me  to  perform  an  operation,  which  her  medical  adviser 
declared  to  be  indispensable.  At  first,  I imagined  it  to  be  an 
abscess  from  the  cavity  from  which  the  pus  was  discharged,  from 
the  strange  sensations  experienced,  and  from  the  greater  frequency 
of  this  disease  over  others  peculiar  to  this  part,  I inserted  a trocar 
into  the  socket  of  the  second  molar,  and,  instead  of  the  gush  of 
matter  I had  expected,  the  passage  of  the  instrument  was  inter- 
cepted by  a hard,  dense,  impregnable  substance.  The  existence 
of  an  exostosis  now  forced  itself  on  me.  To  make  assurance 
doubly  sure,  I had  access  to  several  of  my  medical  friends,  among 


OF  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 


155 


whom,  was  Dr.  Geddings.  On  examination  of  the  part,  the  con- 
sideration  of  the  symptoms,  the  obstinate  nature  of  the  disease, 
they  concurred  with  me  in  opinion,  that  an  exostosis  was  present, 
and  that  the  sole  indication  of  relief  was  its  extirpation.  Accord- 
ingly, on  the  18th  of  August,  the  above  gentlemen  with  several 
others  of  the  profession  were  present,  when  I proceeded  to  per- 
form the  operation.  With  a common  scalpel,  I dissected  away 
the  gum  from  the  canine  tooth  to  the  last  molar,  raised  the  flap 
which  it  made  from  the  alveolar  process,  and  with  a trephine 
opened  into  the  cavity.  Success  was  easier  than  had  been  anti- 
cipated in  consequence  of  the  carious  condition  of  the  process, 
which  was  so  general  on  the  affected  side,  as  to  reach  from  the 
second  incisor  anteriorly  to  the  pterygoid  process  posteriorly. 
In  the  loss  of  substance,  the  external  parietes  of  the  cavity  shared, 
so  that  the  bony  tumour  which  filled  up  and  occupied  it,  could 
be  readily  reached.  The  trephine  was  applied,  the  cavity  en- 
larged, and  the  exostosis  removed.  It  measured  in  circumfe- 
rence three  inches,  was  light,  and  cancellated  on  its  surface,  but 
dense  and  more  resisting  in  its  more  internal  layers.  There  was 
little  or  no  hemorrhage  to  delay  the  operation,  or  any  application 
to  arrest  it.  After  removing  every  spiculum  of  diseased  bone, 
and  cleansing  out  the  cavity,  the  flap  was  replaced  and  to  nature 
was  entrusted  the  cure.  Granulations  sprouted  up  in  full  luxu- 
riance, and  in  the  short  period  of  four  weeks,  the  woman  was  in 
the  enjoyment  of  excellent  health.”* 

That  the  foregoing  was  a case  of  true  exostosis  of  the  maxillary 
sinus,  does  not  admit  of  doubt,  and  it  is  to  be  regretted,  that  more 
of  the  early  history  of  the  disease  and  the  circumstances  connect- 
* American  Journal  of  Medical  Sciences. 


156 


OF  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 


ed  with  its  development  are  not  known.  They  might  perhaps 
lead  to  a correct  explanation  of  the  causes  that  gave  rise  to  it. 
The  presence  of  local  irritants  in  the  immediate  vicinity  of  this 
cavity,  is  proven  by  the  fact  that  the  patient’s  teeth  were  in  a dis- 
eased condition,  but  to  what  extent  they  may  have  contributed  to 
the  production  of  the  exostosis,  it  is  impossible  to  determine,  since 
we  are  not  furnished  with  any  information  concerning  the  stale 
of  her  general  health.  She  may  have  been  affected  with  some 
constitutional  vice,  or  peculiar  habit  of  body,  whereby  the  osseous 
structures  of  the  system  were  predisposed  to  affections  of  this  de- 
scription, requiring  only  the  presence  of  some  local  irritant  to 
fnduce  the  morbid  action  necessary  to  their  development.  That 
such  predisposition  did  exist,  and  that  such  action  was  excited 
by  the  irritation  produced  by  the  diseased  teeth,  I believe  would 
appear,  if  all  the  circumstances  connected  with  the  previous 
history  of  the  case  could  be  ascertained. 

When  the  connection  of  the  exostosis  is  such  as  to  prevent  its 
complete  removal,  the  application  of  the  actual  cautery  to  any 
remaining  portions,  will  prove  serviceable,  by  causing  such  parts 
to  be  exfoliated.  The  history  of  a case  is  related  by  M.  Borde- 
nave,  treated  by  M.  Runge,  in  which  a portion  of  the  exostosis 
was  left,  and  which  ultimately  caused  the  death  of  the  patient.* 
This  would  probably  have  been  prevented  had  an  exfoliation  of 
the  remaining  diseased  portions  of  bone,  been  brought  about  by 
an  application  of  the  actual  cautery. 

Case  XXX.f — The  subject  of  this  case  was  a man  33  years 
of  age.  He  had  been  for  a long  time  afflicted  with  a tumour  in 

* Vide  Memoires  de  l’Academie  Royale  de  Chirurgie,  t.  xiii.  p.  405. 

t Vide  Memoires  de  l’Academie  Royale  de  Chirurgie,  t.  xiii.  obs.  xi.p  408. 


OP  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES.  157 

I 

the  region  of  the  right  antrum.  It  depressed  the  palatine  process 
of  the  maxillary  bone  and  the  palate  bone  of  the  affected  side  in 
such  a manner  as  to  restrict  the  movements  of  the  tongue,  while 
on  the  other  side  it  pressed  against  the  floor  of  the  orbit  so  as  to 
cause  a protrusion  of  the  eye.  Anteriorly,  it  had  elevated  a por- 
tion of  the  maxillary  and  malar  bones  which  covered  it,  and 
extended  to  the  most  dependent  part  of  the  nose,  whilst  posteriorly 
it  extended  as  far  as  the  posterior  mouth.  Its  effects  upon  the 
lateral  parts  were  nearly  the  same  as  those  which  it  had  exerted 
upon  the  others. 

After  having  exposed  the  anterior  parietes  of  the  antrum,  M.  Da- 
vid, sawed  from  below  upwards  to  the  uppermost  part  of  the  pro- 
jection of  the  tumour,  which  was  of  a spherical  shape,  and  nearly 
three  inches  in  diameter,  and  after  having  elevated  that  part,  he 
discovered  the  tumour,  which  was  white  and  hard ; although 
spongy,  and  bearing  a strong  resemblance  to  soft  agaric,  it 
occupied  the  maxillary  sinus.  It  had  changed  the  form  of  this 
cavity  and  increased  its  dimensions  to  an  extraordinary  degree. 
The  greater  portion  of  this  hard  osseous  substance,  although 
firmly  adhering  to  almost  every  part  of  its  bony  envelope,  was 
by  a persevering  employment  of  various  means,  such  as  the 
crotchet,  elevator,  surgeon’s  rasp,  &c.  &c.,  detached  by  M. 
David.  But  in  doing  this,  he  inflicted  some  injury  upon  the  floor 
of  the  orbit,  and  to  some  portions  which  still  adhered  to  the 
palatine  process  of  the  maxillary  bone,  he  applied  the  actual 
cautery,  which  was  repeated  several  times. 

An  opening  was  formed  by  this  operation  four  and  a half 
inches  deep,  and  from  right  to  left,  of  more  than  three  inches,  but 
a cure  was  notwithstanding  speedily  effected  by  it,  which,  had 


158 


OP  EXOSTOSES  OF  ITS  OSSEOUS  PARIETES. 


the  use  of  the  cautery  been  omitted,  would  not  perhaps  have  been 
successful. 

Exostoses  of  the  maxillary  sinus,  often  give  rise  to  other  morbid 
conditions  of  this  cavity,  the  remedial  indications  of  which,  should 
be  properly  attended  to,  as  should  also  those  of  any  constitutional 
affection,  vice  or  habit  of  body  that  the  patient  may  be  labouring 
under  at  the  time. 

When  the  exostosis  is  not  complicated  with  any  other  disease 
of  the  cavity,  the  restorative  energies  of  nature,  after  its  removal, 
will  generally  be  all  that  is  required  to  complete  the  cure. 


CHAPTER  IX. 


OF  WOUNDS  OF  ITS  PARIETES  AND  FOREIGN  BODIES  IN  IT, 

The  walls  of  the  maxillary  sinus  are  sometimes  fractured  by 
blows  and  pierced  by  sharp-pointed  instruments.  Fauchard  men- 
tions a case,  in  which  a canine  tooth  had  been  driven  up  into 
it,*  but  this  is  an  accident  that  rarely  happens.  The  instance 
here  alluded  to,  is,  I believe,  the  only  one  on  record ; and  as 
might  be  supposed,  it  was  followed  by  severe  pain,  and  it  ulti- 
mately gave  rise  to  a tumour  upon  the  cheek  near  the  nose,  and 
three  fistulous  openings,  from  which  a fetid  matter  was  discharg- 
ed. The  sinus  however  having  been  opened  and  the  tooth  taken 
from  it,  a cure  was  at  once  effected. 

It  often  happens  when  the  walls  of  the  sinus  are  fractured  from 
a blow  or  other  mechanical  violence,  that  portions  of  the  bone 
and  foreign  bodies  are  driven  into  the  cavity,  and  which  by 
remaining  there  become  a constant  source  of  irritation  to  its 
lining  membrane,  and,  not  unfrequently  a hidden  cause  of  other 
and  more  malignant  forms  of  disease.  Bordenave  describes  the 
case  of  a French  officer,  who  had  the  walls  of  one  of  his  maxil- 
lary sinuses  fractured  by  a fragment  of  a bomb.  Dressings  were 
applied  to  the  wound,  but  it  did  not  heal,  and  upon  examination 

* Le  Chirurgien  Dentiste,  tom,  i.  page  391. 


160 


OF  WOUNDS  OF  ITS  PARIETES, 


sometime  after  by  M.  Allouel,  several  pieces  of  bone  and  a splint 
which  nearly  filled  the  cavity  were  found.  These  were  removed, 
but  a cure  was  not  immediately  effected;  a fistulous  opening  still 
remained,  and  it  was  not  until  a long  time  after,  when  another 
splinter  came  away,  that  the  external  opening  healed  * The 
same  writer  mentions  the  case  of  a man  who  had  a nail  forced 
head  foremost  by  the  discharge  of  a gun,  into  his  right  cheek  and 
maxillary  sinus.  The  opening  became  fistulous,  and  although  the 
point  of  the  nail  was  subsequently  discharged,  it  was  not,  until 
M.  Faubert  had  removed  the  remaining  part,  that  the  fistula 
closed.-)- 

Wounds  of  the  antrum  are  almost  always  complicated  with 
fractures  of  its  osseous  parietes,  so  that  the  effects  resulting  from 
them  are  more  to  be  dreaded  than  those  which  would  be  produced 
simply  by  the  penetration  of  it  with  a sharp  instrument. 

Treatment. — The  nature  and  extent  of  the  injury  inflicted, 
should  determine  the  treatment  most  proper  to  be  adopted  for 
wounds  of  this  cavity.  Complicated,  as  they  in  most  instances 
are,  with  the  presence  of  extraneous  substances  in  the  sinus,  the 
removal  of  these  constitutes  the  first,  and  not  unfrequently,  the  only 
remedial  indication.  This  should  never  be  neglected.  When 
any  extraneous  bodies,  or  portions  of  bone,  have  been  forced  into 
the  sinus,  these  should  first  be  all  carefully  removed.  The 
external  wound  should  next  be  dressed  with  adhesive  slips  so 
as  to  prevent  the  formation  of  an  unsightly  cicatrix.  If  constitu- 
tional symptoms  supervene,  they  should  be  met  with  appropriate 
remedies. 

The  following  interesting  case  of  a wound  of  the  maxillary 

* Vide  Memoires  de  l’Acadeinie  Royale  de  Cliirurgie,  t.  xiii.  obs.  xiv.  p.  418. 
t Vide  Memoires  de  l’Academie  Royale  de  Chirurgie,  t.  xiii,  obs.  15.  p.  417. 


AND  FOREIGN  BODIES  IN  IT. 


161 


sinus,  inflicted  with  a dirk-knife,  reported  by  R.  S.  VVelden,  stu- 
dent of  medicine,  and  treated  by  W.  H.  Donne,  M.  D.,  of  Louis- 
ville, Ky.,  is  taken  from  the  Western  Journal  of  Medicine  and 
Surgery. 

Case  XXXI.— “Schuti,  a gardener,  aged  42  years,  a native  of 
Germany,  in  a rencontre  with  an  athletic  man,  on  the  3d  of  May, 
1840,  was  struck  with  a dirk-knife,  which  entered  about  an  inch 
above  the  right  superciliary  arch,  passed  through  the  correspond- 
ing eyelid  downwards  and  backwards,  evacuating  the  humours 
of  the  eye,  and  penetrated  the  antrum.  The  globe  of  the  eye  was 
divided  by  a vertical  incision,  through  which  the  aqueous  humour 
escaped ; the  iris  was  extensively  detached  at  the  ciliary  margin, 
and  could  be  partially  seen  through  the  transparent  cornea — its 
surface  being  somewhat  obscured  by  small  coagula.  The  he- 
morrhage was  slight  and  easily  controlled  by  moderate  pressure. 
The  patient  complained  of  intense  pain  in  the  temple  and  cheek 
of  the  wounded  side,  shooting  deep  into  the  orbit.  Three  points 
of  interrupted  suture  were  used  to  approximate  the  edges  of  the 
divided  eye.  Lint,  saturated  with  laudanum  and  warm  water, 
constituted  the  dressing. 

May  4th. — Some  tumefaction  in  the  eyelid  ; pulse  110;  tongue 
coated  and  dry;  skin  hot;  patient  has  spent  a very  restless  night. 
Ordered  following  medicine,  tart,  emetic,  gr.  i. ; sulph.  magne- 
sia, § ss. ; to  be  dissolved  in  one-half  pint  of  water,  and  a table- 
spoonful to  be  taken  every  half-hour,  until  nausea  is  induced — after 
which  the  interval  may  be  increased. 

May  5th. — Bowels  freely  evacuated ; pain  less ; skin  moist ; 

% 

pulse  90  and  soft.  From  this  period  until  the  wound  healed— the 

space  of  three  weeks — no  constitutional  symptoms  of  an  untoward 
20 


162 


OF  WOUNDS  OF  ITS  PARIETES, 

character  occurred.  The  patient,  however,  contended  that  a 
portion  of  the  knife-blade  remained  in  the  roof  of  his  mouth.  But 
on  the  most  careful  examination  no  foreign  body  could  be  de- 
tected. 

On  the  10th  of  August,  1842,  Mr.  Schuti  called  and  requested 
Dr.  Donne  to  examine  his  mouth,  stating  that  for  six  months  past 
he  had  been  annoyed  by  a rough,  projecting  substance,  which 
some  person  had  informed  him  was  a piece  of  dead  bone,  but 
which  he  believed  to  be  the  point  of  the  knife,  that  had  been  driven 
down  into  the  bone  by  the  violence  of  the  blow.  On  looking  into 
the  mouth,  a small  black  speck  was  discernible  about  one-half  inch 
from  the  interval  between  the  first  and  second  molar  teeth.  The 
parts  adjacent  were  somewhat  tumefied  and  inflamed.  Dr.  Donne 
made  several  attempts  to  extract  this  body  with  a pair  of  common 
dissecting  forceps,  but  found  it  immovably  fixed  in  the  substance 
of  the  bone.  By  dissecting  around  it  with  a bistoury,  down  to 
the  palate  process  of  the  superior  maxillary  bone,  he  was  enabled 
to  get  a firmer  hold,  and,  with  a pair  of  curved  tooth-forceps, 
succeeded  in  removing  a fragment  of  the  blade,  one  and  one- 
fourth  inches  in  length,  and  three-fourths  in  width  at  the  widest 
part ; the  extraction  was  not  effected  without  considerable  vio- 
lence, and  was  attended  with  extreme  suffering.  The  fragment 
came  out  with  an  audible  snap,  which  induced  those  present  to 
suppose,  at  first,  that  it  had  been  broken ; but  on  inspecting  its 
surfaces  closely,  they  were  found  similarly  oxidized,  and  wanting 
the  lustre  which  a recent  fracture  had  presented.  Upon  probing 
'he  aperture  through  which  the  fragment  had  been  extracted,  no 
ither  piece  could  be  detected.  This  opening  would  scarcely 
dmit  the  curved  probe  which  Dr.  Donne  passed  into  the  antrum. 


AND  FOREIGN  BODIES  IN  IT. 


163 


in  order  to  satisfy  himself  that  the  whole  of  the  foreign  body  was 
removed.  The  next  day  there  was  a slight  discharge  from  the 
aperture,  though  the  patient  has  suffered  very  little  pain  since  the 
operation.” 

The  foregoing  is  certainly  one  of  the  most  singular  cases  of 
which  we  have  any  account,  and  the  most  remarkable  circum- 
stance connected  with  it  is,  that  no  more  injury  should  have  re- 
sulted from  the  presence,  for  so  long  a time,  in  the  maxillary 
sinus,  of  the  portion  of  the  blade  of  the  knife  that  had  been  broken 
off.  In  the  cases  previously  noticed,  as  reported  by  Bordenave, 
disease  of  the  mucous  membrane  of  the  antrum,  and  the  discharge 
of  a fetid  sanies  resulted  from  the  presence  of  the  foreign  bodies 
in  this  cavity.  The  same  effects  were  also  produced  in  the  case 
described  by  Fouchard,  of  the  canine  tooth  which  had  been  for- 
ced up  into  it. 

That  foreign  bodies  are  sometimes  admitted  into  the  maxillary 
sinus  through  wounds  penetrating  its  exterior  parietes,  has  already 
been  shown,  but  that  they  should  gain  access  to  it  in  any  other 
way,  would  seem  almost  impossible.  The  smallness  and  peculiar 
situation  of  the  opening  which  communicates  with  it,  is  such,  as 
one  would  think  would  preclude  the  introduction  of  extraneous 
substances  of  any  kind  through  it,  yet  they  have  been  found  here 
when  they  could  not  have  gained  admission  in  any  other  way. 
There  are  several  well  authenticated  cases  on  record  in  which 
worms  have  been  found  in  this  cavity.  The  case  mentioned  by 
Bordenave  in  Obs.  12,  page  380,  vol.  13,  of  the  Memoirs  of  the 
Royal  Academy,  of  a diseased  maxillary  sinus,  from  which  seve- 
ral worms  were  at  different  times  discharged,  does  not  prove  that 
they  obtained  admission  into  it  through  the  nasal  opening,  and 


164  OP  WOUNDS  OF  ITS  PARIETES, 

thus,  as  some  writers  have  conjectured,  gave  rise  to  the  disease 
with  which  it  was  affected.  In  this  case,  a fistulous  opening  from 
the  cavity,  had  existed  for  a long  time  previously  to  the  discharge 
of  the  worms  from  it,  and  it  is  very  probable  that  they  introduced 
themselves  through  this.  A cause  sufficient  to  have  produced  the 
disease  in  the  sinus,  had  been  operating  for  two  years,  imme- 
diately preceding  its  manifestation.  The  patient  during  the  whole 
of  this  time  was  affected  with  pain  in  the  superior  teeth  of  the 
affected  side. 

Deschamps  says,  his  colleague  of  la  Charite  Hospital,  found  a 
worm,  in  the  maxillary  sinus  of  a soldier,  whom  he  was  dissecting^ 
four  inches  long,  and  the  same  writer  informs  us  that  a similar 
example  is  furnished  in  the  Journal  of  Medicine.  The  particulars 
of  a case  which  came  under  the  observation  of  Mr.  Heysham, 
physician  of  Carlisle,  taken  from  a work  entitled  “Medical  Com- 
mentaries,” are  contained  in  Cooper’s  Surgical  Dictionary.*  The 
subject  of  this  case  was  a strong  woman,  sixty  years  of  age,  who 
was  in  the  habit  of  taking  a great  deal  of  snuff.  She  was  affected 
for  a number  of  years  with  severe  pain  in  the  region  of  the  max- 
illary sinus,  which  “extended  over  one  side  of  the  head.”  She 
was  never  entirely  free  from  this  pain,  but  it  was  greater  in  cold 
than  in  warm  weather,  and  for  the  purpose  of  obtaining  relief  she 
had  been  twice  salivated,  and  had  taken  various  anodyne  medi- 
cines. The  pain  however,  instead  of  being  mitigated  by  these 
means,  became  more  severe.  Her  teeth  on  the  affected  side  were 
all  extracted,  and  as  a last  resort  the  maxillary  sinus  was  perfo- 
rated. But  this,  for  several  days  did  not  give  any  relief.  Injec- 
tions of  bark  and  “elixir  of  aloes,”  were  thrown  into  it,  and  “on 
* Vide  Art.  Antrum,  page  155. 


AND  FOREIGN  BODIES  IN  IT. 


165 


the  fifth  day  a dead  insect”  of  more  than  an  inch  in  length,  and  as 
thick  as  a “common  quill,”  was  removed  from  this  cavity. 

But,  instances  of  the  introduction  of  insects  or  foreign  bodies 
of  any  description,  into  the  antrum  through  the  nasal  opening, 
fortunately,  are  so  exceedingly  rare,  that  the  Memoirs  of  Medi- 
cine do  not  furnish  more  than  four  or  five  well  established 
examples. 

The  signs  indicative  of  the  presence  of  insects  or  foreign 
bodies  in  the  maxillary  sinus,  are  so  obscure,  that  the  fact  can 
only  be  ascertained  by  perforating  the  cavity  and  on  an  ex- 
amination of  its  interior.  Some  say  that  foreign  bodies  here 
cause  an  itching,  crawling  or  tickling  sensation  in  the  substance 
of  the  cheek.  But  this  is  an  uncertain  diagnosis,  for  such  sensa- 
tions are  not  unfrequent  in  the  region  of  this  cavity.  That  they 
sometimes  cause  great  pain,  is  proven  by  the  history  of  the  case 
related  by  Mr.  Heysham,  the  particulars  of  which  I have  just 
noticed,  but  this  like  the  other  signs,  is  not  peculiar  to  occurrences 
of  this  sort  alone.  It  is  more  or  less  common  to  all  the  morbid 
affections  of  this  cavity. 

The  proper  remedial  indication  for  foreign  bodies  in  the  an- 
trum, is  their  removal.  When  insects  are  discovered  here,  injec- 
tions of  oil  and  tepid  water  are  recommended.  This  constitutes 
about  all  the  treatment  necessary  to  be  employed  in  cases  of  this 
kind. 


V 


. . v- 

. 

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